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Nathalie
06-05-2009, 08:47 PM
Hello All,
Time to introduce ourselves.
My Phillip who will be turning 12 in a few months is a Collie/Beagle mix and has been diagnosed with PDH and Hypothyroid last month after being misdiagnosed for the past 1.5 years.
It’s been a long journey so far and I just hate to see him in such rough shape.

The vet who is currently treating Phillip suggested not to ‘load’ but to start him on a Lysodren ‘Maintenance’ dose to avoid him feeling too ‘crummy’ and she said in her experience this protocol works just as well.
I read anything and everything about PDH and its treatment but everyone seems to follow a loading protocol.

Now here is my question … If I understand this correctly ….Phillip’s weight is 62 lbs (28,58 kg) – 50 mg per kg = Maintenance dose of 1500 mg per week, divided into 2 doses per week?

He is currently getting 1500 mg of Lysodren 2x per week.

I would appreciate if someone could comment on the Lysodren regiment … Does it make sense to not ‘load’? Any pro/con’s?
I am also a bit confused what the proper Maintenance dose would be for my Phillip since the vet calls the 3000 mg per week a Maintenance dose but if I did the math correctly his Maintenance dose would be 1500 mg per week.

So far Phillip had 6 doses of 1500mg of Lysodren and is tolerating it well with no noticeable adverse reactions. There might have been a bit of an improvement in not being as hungry and thirsty at times but since yesterday he is ravenous again, eating anything and everything.

He supposed to get 1500 mg of Lysodren tomorrow and next week Wednesday and is booked in for an ACTH test on Thursday.
Any thoughts and recommendations would be greatly appreciated.

Thanks in advance,
Nathalie (Hamilton, ON Canada)

Phillip, Collie/Beagle mix, 11.7 years old, M/N, 62 lbs. (28.58 kg), Cushing's disease/PDH (dx May 16, 09), started on May 30, 09 with 1500 mg Lysodren 2x per week), Hypothyroidism (dx May 30, 09) 0.4 mg Thyro-Tabs 2x daily Diet: Urban Wolf (raw), Flaxseed Oil, No vacc. for past 6 years, no pesticides for past 3 years.

BestBuddy
06-05-2009, 08:59 PM
Hi Nathalie and welcome to you and Phillip.
I am not too familiar with the lysodren protocol but I would think that at double the dose it would not be considered maintenance but a low type of loading. Others will be along soon with more info but I just wanted to say hello and welcome.
Jenny
PS Keep a check on the thyroid situation as sometimes a cushing dog can have what is called "sick euthoid syndrome"(sp??) and once the cortisol is back in range so is the thyroid.

MiniSchnauzerMom
06-05-2009, 09:16 PM
Hi Nathalie,

Just wanted to drop in and welcome you and Phillip. I have never used Lysodren so will leave any commenting to those who are experienced in using it with their furbabies.

You have come to the right place for information and support and I'm sure others will be along shortly to assist you. I'm glad that Phillip is doing well so far and without any problems.

Give Phillip some extra pets from me!

Louise

StarDeb55
06-05-2009, 09:33 PM
I'm certainly glad that you have found us Nathalie, welcome to both you & Phillip!

Let me give you some basics about lysodren loading vs. maintenance dosing. First of all, you are correct about the dosage you have calculated for your boy. Dosage is calculated based on 25-50 mg./kg. body weight. When you are loading, the purpose is to necroses (destroy) enough of the adrenal cortex to bring down the cortisol production to a more healthy level which is 1-5 mg./dl for our cushpups. You are giving the loading dose daily, split into 2 doses. Once your pup shows signs of loading, then you have a stim done to confirm that the cortisol is within the 1-5 range. You then take that same daily loading dose, & split that into several doses over the week. A lot of vets have their own preference as to how frequently you give a maintenance dose. Most protocols state that you do not want to do a maintenance dose less than twice a week. Most vets seem to prefer 3-4 times per week for maintenance dosing as it keeps the blood levels of the med more stable & does not give the adrenal glands a chance to regenerate. For instance, my Harley gets his maintenance dose 3 times per week. Your vet is giving double the max maintenance dose for a pup Phillip's size which gives me cause for concern. I really think this more of a low level loading than a maintenance dose. This protocol your vet is using is a real deviation from any standard lysodren protocols that I'm aware of, so I'm wondering how much actual experience your vet has in treating Cushpups & using lysodren?

Could you tell us more about your boy's Cushing's diagnosis? For instance, what specific symptoms were bothering him that led you to go to the vet? What tests were done to diagnose the Cushing's? It would be really helpful if you could get copies of all tests that were done & post the actual results for us. Most of us in this group keep files on our babies at home as you never know when they might come in handy especially if you end up at a strange vet. We ask a lot of questions of new members, but that just helps to understand your boy's medical background so we can give you the most appropriate feedback from the group's collective experience.

We are here to help in any way we can. Looking forward to hearing more.

Debbie

frijole
06-05-2009, 09:49 PM
Nathalie

Hi and welcome! My dog has been treated successfully with lysodren for 3 yrs. She is now 15 1/2! My original vet was unfamiliar with treating cushings (although she didn't admit it ;)) and she set up a peculiar and very low loading recommendation. Something made me think twice about it and I went to the internet and found this group.

They helped me save my dog's life I have no doubt. I learned what the proper protocols for lysodren are and after switching vets and finding one that followed protocol my little ole girl has had a normal and happy 3 yrs.

I encourage you to read up and become familiar with the disease and with treatment with lysodren so you are able to be Phillip's voice in this. Here is a link to information on lysodren and how it works:
http://www.k9cushings.com/forum/showthread.php?t=181

If you could post the test names and results (numbers) that were used to diagnose we could help you better.

I am glad you found us and don't worry - we have been down the path. It is scary at first but knowledge is power and you will be fine.

Kim

Nathalie
06-05-2009, 11:41 PM
Thank you so much for the warm welcome and the quick reply’s.

Ok here is more background on my Phillip and what happened so far … sorry, this is going to be long.
About 1.5 years ago I took Phillip to a vet because he had slight occasional tremors in his hind legs (very infrequent) and had just slowed down quite a bit. He used to go squirrel hunting for hours but did not pay much attention to them except when they where crossing his path. I was told there was nothing wrong with him he is just getting older. The tremors in the hind legs became more frequent, now in both legs and he started to eat anything and everything including dog poop (Phillip had never done this before and would have done everything to avoid even stepping in poop). Back to the vet and she said he has Lyme and an enlarged spleen and probably arthritis, not much that can be done …..… This all just did not sit right with me and I came across a website about Cushings desease that showed a dog with Cushings and talked about the symptoms and I knew that was it – my Phillip had Cushings. Back to the vet with the picture/information of the Cushings dog. She said no way – Phillip does not have Cushings. That was last September. With all the research I have done since then I know that even back then he looked like a typical Cushings pup.
I continued to do more research and took matters into my own hands and started of with a complete blood panel.

These are the tests that came back not being within normal range:

Test Results Reference Range
ALP 2475 24-141
ALT 165 5-95
Glucose 7.3 3.6-7.0
MCHC 374 320-360
Platelets 568 165-550

I then emailed Dr. Jean Dodds to ask her opinion and she said that the extremely high ALP levels often point to an overactive adrenal gland metabolism and she recommended testing for Cushings and I had a Low Dose Dex test done which confirmed Phillip having PDH. I also send a blood sample to Jean for a full Thyroid panel which confirmed low Thyroid – see result below and Jeans recommendation.

Low Dose Dex test results:

Cortisol (0h) 157
Cortisol (2h Dex) 37
Cortisol (6h Dex) 13
Cortisol (8h Dex) 22

Thyroid Panel:

Test Requested Results Reference Range Units
T4 PLEASE NOTE NEW RANGES
T4 ¯ ¯ 0.60 0.80 – 3.80 g/dL
verified by repeat analysis
FREE T4
Free T4 ¯ 0.65 0.60 – 2.50 ng/dL
T3
T3 42 30 - 70 ng/dL
FREE T3
Free T3 2.1 1.6 – 3.5 pg/mL
THYROGLOBULIN AUTOANTIBODIES
Thyroglobulin Autoantibody 3 NEGATIVE %

Per Jean: Thyroid levels are too low here, and support the clinical signs. TgAA is normal, so thyroiditis is not the reason for the low T4. Recommend 6-8 weeks of Soloxine® or equivalent product at 0.1mg per 15 lbs twice daily (e.g. 0 . 4 mg BID) is suggested, followed by retesting thyroid profile 4-6 hours post-pill to monitor response levels.

We finally had it confirmed – Phillip has Cushings and is Hypothyroid, at least now we can do something about it.
I made an appointment with Phillip’s current vet and faxed all the blood work ahead of time to giver her time to through everything.
She did not want to put Phillip on Thyroid meds because she believes the low Thyroid is only a symptom of Cushings and we would have to keep him on it for life once started.
However, I went with Jean’s recommendation and put him on Thyro-Tabs 0.4 mg 2x per day.
I checked with Jean and she said that “The fact that many veterinarians believe incorrectly that once you put an animal on thyroxine, he/she needs to be on this medication for life. In fact, if you stop the thyroxine even after years of therapy, it takes 5-6 weeks for the pituitary-thyroid axis to be reactivated to its original capacity [whether low or normal] .”

These are his symptoms:

increased/excessive appetite, sagging, bloated, pot-bellied appearance, loss of muscle mass (hind end), shaking of hind legs, exercise intolerance, heat intolerance, intermittent wheezing when laying down (inhale), reluctance to jump on higher surfaces, poop eating, wood eating, eyes water at times (never used to)
right ‘third eyelid’ pink and some what constricted, sore on right elbow, seeking cool surfaces to rest, moves slower/needs to rest more during walks, excessive panting, increased water intake, premature aging (graying in face), lost almost all interest in squirrels, not as mentally alert, poor coat, thinning coat on side of belly towards hind legs, Lumps under right armpit, growths under eye, Dark pigmented skin on stomach, brittle teeth

Phillip has also a Grad 3 heart murmur.

I asked Phillip’s vet during the first appointment if she is experienced in treating Cushings and she assured me that she had treated many Cushings dogs with good results using the protocol I described in my first post. We had a full hour talk and I liked what she said and the way she treated my Phillip sitting with him on the floor (unfortunatly I had a lot of negative experienses with vets in the past 4 years - up until last winter I used to be involved in rescue and foster dogs). The main goal is quality of life, and to hopefully bring down the cortisol level to something where he feels as best as possible and not a perfect test result number.

I hope I did not forget anything important. Let me just say I am very grateful for any help and suggestions from this group.
It just breaks my heart to see my Phillip in this condition :( and I it was not an easy decision to start him on Lysodren but I read so many success story’s that I wanted to give this a try. Giving him those first few pills felt like I am putting poison into my dog. However, I am over this now and just want the Lysodren to kick in and see some improvements. Last week Phillip broke one of his canines while chewing a bone, and his sore on his elbow has gotten worse and is bothering him now so I have to put foam on it and wrap it because he wants to lay on the cold tile floor. 2 days ago I started him on AntiFlam by Omega Alpha to hopefully help with his sore elbow and any other inflammatory aches that might get unmasked once the cortisol is coming down.

Thanks for listening,
Nathalie and Phillip

frijole
06-06-2009, 11:28 AM
Nathalie,

Thanks for all the information as it really helps. Did your vet do a test called an ACTH test?
http://www.k9cushings.com/forum/showthread.php?t=207
http://www.k9cushings.com/forum/showthread.php?t=196

Did the vet give you prednisone to have on hand?

The reason that acth tests are done prior to commencing lysodren is that it tells you the cortisol levels of your dog PRIOR to starting the drug. It gives you a baseline from which to measure.

Then as we have shared you "load" your dog by giving daily dosing. The objective of daily dosing is to reduce the cortisol being produced by the adrenals. The whole goal of giving lysodren is to get your dog to a normal level that can be maintained by weekly dosing. The goal (as outlined in the vet protocols) is a cortisol reading using ACTH testing of between 1 and 5.

My concern is that Phillip will not get any relief by skipping the loading phase because his cortisol levels will not be sufficiently reduced. Please find out if the test was done and if so we are looking for the 2nd number which will tell us how high his levels were.

I totally remember giving my dog the first lysodren and it was scary. Fear of the unknown. This group held my hand thru the process and we did it. Like any drug (even aspirin!) you have to respect it and know how it works. You have done a great job of representing your dog by keeping records and asking questions.

I suggest you read up (there is a ton of info in our resources threads) and keep asking us questions. At some point you might want to regroup with the vet to discuss the dosing. That is your call.

Best,
Kim

Nathalie
06-06-2009, 12:41 PM
Thanks for all the feedback so far.

Kim, I did not request to have an ACTH test done prior to starting Lysodren. Perhaps I am wrong here, but it was my understanding that that an ACTH test is indicated after loading and after changes in dosage. There is also the issue of $ so I tried doing only the tests that gives us the most value/information. Perhaps it would have been ‘nice’ to get a baseline but there is only so much money to go around with 6 pets in the house. What I appreciate about this vet is that she has no problem to work WITH me, research any info I give her and really tries to keep cost down so we can still afford to eat.

Phillip is booked in for an ACTH test next week Thursday after receiving his last dose of Lysodren on Wednesday.
Yes, I do have prednisone on hand.
I have extensively read the literature and do understand the objective of a loading phase, but what I don’t understand is why giving Phillip 1500 mg 2x per week for 4 weeks would not erode the adrenals to the same extend as giving 1500 mg every day for 8 consecutive days, assuming that 1500 mg is a high enough dose to begin with. It just seems to be a bit more “gentler” (if the word ‘gentle’ can even be used in conjunction with a chemo drug) then assaulting the body on a daily basis.
BUT, perhaps I am missing something here, so please correct me if I have got this all wrong. :confused: After all, you guy’s been through this.
I need to get all my ducks in a row before Thursdays appointment as I already mentioned to the vet that we might want to increase the frequency depending on the ACTH result.
Thanks,
Nathalie
BTW – I posted some pictures of my guys ;)(the first picture also shows 2 previous fosters) http://www.k9cushings.com/forum/album.php?albumid=59

Dollydog
06-06-2009, 12:58 PM
Hi Nathalie and Phillip and welcome,
I've been following your thread with interest today. My Lady is on trilostane so have no experience with Lysodren. I can tell from your posts that you're doing a thorough job in approaching the treatment for Phillip. He is a lucky boy to have you on his side!

We live in Northwestern Ontario, 3 hours east of Thunder Bay and 4 hours west of Sault Ste Marie. Our closest clinic is in Thunder Bay and we have a travelling vet who comes from the Sault once a month. We were living in Nevada while we got Lady regulated on trilostane and insulin for her diabetes. Her care has been a challenge since returning home to Marathon in Nov/07.
I'm sending a PM,
Jo-Ann & Lady :)

frijole
06-06-2009, 01:22 PM
Nathalie,

I totally understand your mode of thinking about a gentler approach. Quite simply, if it was that simple we would have all done it. Every dog is different in how they respond to lysodren and the speed with which it works. My dog had daily dosing for 2 1/2 months. Yes. So the weekly thing would have never worked.

Since I am not a vet I can only share what I have seen reading here for 3 years. I don't recall ever seeing a weekly approach work for pituitary and adrenal cushings.

I understand the money thing - cushings is expensive to diagnose. Please know it gets much better after you get the numbers down. The value of the acth before starting is you know how far you have to go. It would also tell you your progress when you have the next one done. Please share the results of the test when you get it. It is helpful (to you) to start a file and keep copies. Trust me, at some point you will want to refer to something and its easier to have it on hand. :)

Glad you have the prednisone and have read up on lysodren so you know when to give it. Do keep us posted on how things are going. Are you measuring water intake to track changes?

Kim

acushdogsmom
06-06-2009, 01:49 PM
I have extensively read the literature and do understand the objective of a loading phase, but what I don’t understand is why giving Phillip 1500 mg 2x per week for 4 weeks would not erode the adrenals to the same extend as giving 1500 mg every day for 8 consecutive days, assuming that 1500 mg is a high enough dose to begin with. The short answer to that question is that the adrenal gland tissue tends to grow back. If it didn't grow back, we could just give the loading dose and stop treating after that. But it does grow back, and that's why we have to continue giving weekly doses after the loading is completed.

If you don't load, what usually happens is that the adrenal gland tissue grows back (in between the lysodren doses that you are giving) enough that you never really get the adrenal glands "shaved back" enough and the cortisol production never gets to the lowish level that we need to achieve for good control. Without a loading dose, it's sort of like taking a few steps forward and then a few steps back.

The way I learned it, you want to load with daily doses to get the cortisol down to a desired level, and then give weekly maintenance doses to keep the cortisol production down to where you got it with the loading. Sort of like getting a haircut and then having a little trim every week to keep your hair at a certain specific length. :)

I suppose that you can try it though, and see if you can get the cortisol down to acceptable levels the way your vet is having you give the Lysodren now. But what we've seen here (many times) with people who have tried to do it that way is that it doesn't work.

Is your vet planning to have you give this "double the usual weekly maintenance dose" for a long time? Because if that's the plan, I'm pretty sure that you'll end up giving more Lysodren over time than you would if you just loaded (until cortisol is low enough, which is not necessarily 8 or any particular number of full days in a row, by the way) and then went to 1500 mg per week as a maintenance dose.

Does your vet think that this double the usual weekly dose will lower the cortisol sufficiently (eventually) and is planning that at that point for you to go to a 1500 mg weekly maintenance dose? How often will your Vet be doing an ACTH stim test to see where the cortisol production is at? With the method your vet is using (and assuming you are indeed aiming to get the cortisol to the same low level of production that we aim for when we do a loading) you will likely have to do many more ACTH stim tests until you get the cortisol lowered enough, than you would if you did a loading dose (after which one stim usually is enough to prove the levels are low enough)

Has your vet explained all of the goals of treatment to you?

It's possible, I suppose, that your vet is not really trying to get the best control possible, maybe taking into consideration your dog's age and overall health (heart etc) and thinking that it's better to lower the cortisol production as much as can be achieved with the dosing you are doing now than if you were doing nothing at all.

Nathalie
06-06-2009, 01:55 PM
Jo-Ann, thanks for the welcome and your confidence in Phillip’s treatment approach. ;)

Kim, I hear what you are saying. 2 ½ months of daily dosing …. Yikes – I am already chain-smoking since we started this Cushings journey …

Since I was the one that ordered the blood tests I have all the original paperwork which I have also scanned into the computer.
I certainly will post the results from the ACTH test once in.
I think we probably have to look into a change of protocol and look at something that resembles more of a loading protocol.

Since there are 3 dogs and 3 cats in the house I don’t see how I could measure his water intake….. instead I keep a close eye on frequency and drinking duration and use his response to food a the main measure if the Lysodren kicked in or not as well as his overall appearance.
Thanks,
Nathalie

acushdogsmom
06-06-2009, 02:51 PM
Hi again,

I just re-read your thread and just noticed the LDDS test results that you posted. Although I agree that the symptoms you described sound very much like Cushings symptoms, I am not sure I understand how your vet can be sure that the Low Dose Dex Suppression test results are consistent with a diagnosis of Cushings (and Pituitary Cushings in particular)


Low Dose Dex test results:

Cortisol (0h) 157
Cortisol (2h Dex) 37
Cortisol (6h Dex) 13
Cortisol (8h Dex) 22

Since you are in Canada I am assuming those test results are in nmol/L and although you didn't post the normal reference ranges, I believe that the normal reference range for the 8-hour LDDS test number is usually something like "less than 10 nmol/L" (and I think the 6-hour reference range would be the same as for the 8-hour number)

So in the very strictest interpretation of the test results, I guess one could say that since the 8 hour result is 22 nmol/L (which is higher than the normal result of less than 10 nmol/L) that would be consistent with a dx of Cushing's.

And since your dog suppressed to 13 nmol/L (0.47 ug/dl) at 6 hours and then "escaped" that level of suppression and rose to 22 nmol/L (0.79 ug/dl) at 8 hours, it could maybe be said that the Cushing's is likely Pituitary.

But in looking at those numbers again, they really aren't very much off (higher than) the normal reference ranges. And although your dog does have many of the symptoms of Cushing's, I think if it was my dog, I'd want to have a more conclusive Cushing's diagnosis than the sort of borderline non-suppression on an LDDS test that really could be attributed to stress or non-adrenal illness.

I think that doing an ACTH stim test before starting any treatment would have been useful, more than just as a baseline ... it could have told you just how high your dog's cortisol production really is and if it is or isn't really high enough to be consistent with a cushing's diagnisis.

If the cortisol production on a stim test wasn't all that high, there could be other reasons for the cushings-like symptoms that your dog is displaying, maybe even "atypical cushing's", which, coincidentally enough, could be effectively treated with a maintenance dose of Lysodren in some cases (ie with no loading). Atypical Cushing's is diagnosed by doing an ACTH stim test but the test needs to be sent to a particular Lab in the States at the University of Tennessee where they measure cortisol and other adrenal hormones, known as the "adrenal intermediates".

An ultrasound would also have been a test that I would have requested, before starting treatment, to see if the adrenals are enlarged the way they would be in a Cushing's dog. In my opinion, ultrasound gives you the most bang for your buck, giving information about not only the adrenal glands, but also about the health status of many other internal organs.

I understand that you have more than just one dog in your family, I understand about financial constraints, too. I'm not a vet, just an ordinary person who had a dog with Cushing's (successfully treated with Lysodren for more than 6 years) and who loves her dogs, as you do ... but I'm just not completely convinced that your dog has been conclusively and correctly diagnosed or that the treatment is being done correctly. On the other hand, if your dog is actually "atypical", the maintenance dosing of Lysodren (and maybe even at just 1500 mg per week) might be the correct way to treat it. Thing is, we don't really know that your dog has that "atypical" type of Cushing's, and I'm honestly not sure anyone can really know (from the test results you posted) that he really has PDH either.

What I do know for sure is that you'll keep a close eye on your Phillip and that you will stay in close touch with your vet as well.

------------
edited to add: Coincidentally, we have another new member whose dog has just been dxed with "Atypical" Cushing's (elevated adrenal hormones other than cortisol) and although the test result she posted is the ACTH stimulation test plus full adrenal hormone panel result from UTenn, the cortisol pre number on the test is almost exactly the same as your dog's pre dex test suppression number of 157 nmol/L (57.8 when "translated" from the UTenn units of measure = 5.78 ug/dl, which = 159.4 nmol/L). So her pre test resting number was high too. That dog has just recently started taking maintenance doses of Lysodren (no loading)

We can't extrapolate from this and say that your dog has the same condition, especially since the two tests (ACTH stim and LDDS) are completely different and the results of the two different tests tell us completely different things, but the other dog does have atypical cushing's (confirmed with testing) and is also on a maintenance dose of Lysodren (with no loading) and I thought you might be interested to follow that thread.

http://www.k9cushings.com/forum/showthread.php?t=589

Also, here's a link to a thread in our Resources forum about "Atypical" Cushing's, in case you want to read up on that:

http://www.k9cushings.com/forum/showthread.php?t=198

Nathalie
06-06-2009, 03:05 PM
Cushy,

I am not sure how to use the ‘Quote’ feature so I am just copying the quotes for now.

“If you don't load, what usually happens is that the adrenal gland tissue grows back (in between the lysodren doses that you are giving) enough that you never really get the adrenal glands "shaved back" enough and the cortisol production never gets to the lowish level that we need to achieve for good control. Without a loading dose, it's sort of like taking a few steps forward and then a few steps back.

The way I learned it, you want to load with daily doses to get the cortisol down to a desired level, and then give weekly maintenance doses to keep the cortisol production down to where you got it with the loading.”

To me this sounds like that during a loading phase the objective is to damage the adrenals enough to compensate for the re-growth that takes place once the dog is on a maintenance does or maybe to damage it enough that it can not re-grow too much while on the maintenance dose. I am just trying to wrap my head around this ….
Do you have a link to some documentation written by a vet that I could print out and show to Phillips vet that talks about why loading must be done?

“Is your vet planning to have you give this "double the usual weekly maintenance dose" for a long time? Because if that's the plan, I'm pretty sure that you'll end up giving more Lysodren over time than you would if you just loaded (until cortisol is low enough, which is not necessarily 8 or any particular number of full days in a row, by the way) and then went to 1500 mg per week as a maintenance dose.”

Good question – last time I spoke to her we agreed to see how he is doing on the current protocol and then do an ACTH test after 8 doses of 1500 mg (1 month) and take it from there.

“Does your vet think that this double the usual weekly dose will lower the cortisol sufficiently (eventually) and is planning that at that point for you to go to a 1500 mg weekly maintenance dose? How often will your Vet be doing an ACTH stim test to see where the cortisol production is at? With the method your vet is using (and assuming you are indeed aiming to get the cortisol to the same low level of production that we aim for when we do a loading) you will likely have to do many more ACTH stim tests until you get the cortisol lowered enough, than you would if you did a loading dose (after which one stim usually is enough to prove the levels are low enough)”

When we originally started Phillip on Lysodren she believed that the double of the usual weekly dose would lower the cortisol sufficiently. I briefly touched base with her last week and that is when I mentioned that perhaps we need to change protocols and switch to something more of a loading protocol. However, this I will need to discuss during next weeks appointment. We have not discussed a true Maintenance dosage yet – just taking it one step at a time.
Since he is showing no improvement so far, does it even make sense to do an ACTH test next week?
When I suggested increasing the frequency of the Lysodren dosage the vet said she does not want to do this without doing an ACTH.


“Has your vet explained the goals of treatment to you?

It's possible, I suppose, that your vet is not really trying to get the best control possible, maybe taking into consideration your dog's age and overall health (heart etc) and thinking that it's better to lower the cortisol production as much as can be achieved with the dosing you are doing now than if you were doing nothing at all.”

We agreed on that the most important goal is to get Phillip feeling better. We are aiming for quality of live not quantity. Keeping also my rather sad financial situation in mind. We are not looking for necessarily perfect cortisol levels – the aim is to bring them down to a level where Phillip feels well.
Aside from Cushings and a Grade 3 heart murmur Phillip has no known health issues that I am aware of.

Ok, now I am getting stressed out!
By the sounds of all of the reply’s so far it sounds that you all would switch Phillip to a true loading protocol. Which in the long run would mean less Lysodren and less testing?

Nathalie

Nathalie
06-06-2009, 03:38 PM
Cushy – thank you for taking the time to comment on my Phillip’s situation in such great detail!

“I believe that the normal reference range for the 8-hour LDDS test number is usually something like "less than 10 nmol/L" (and I think the 6-hour reference range would be the same as for the 8-hour number)”

That is correct. Sorry for not posting the normal reference ranges.
When the vet faxed me the result of the LDDS test she also said ‘The fact that the levels did not get suppressed confirms Cushings. Since the 6 h post injection is less then the 8 h it is likely a pituitary tumor rather then an adrenal tumor. Tx would be starting Lysodren @ 1500 mg every 3 days (or twice per week) and rechecking with ACTH stim test in 4 weeks’

“But in looking at those numbers again, they really aren't very much off (higher than) the normal reference ranges. And although your dog does have many of the symptoms of Cushing's, I think if it was my dog, I'd want to have a more conclusive Cushing's diagnosis than the sort of borderline non-suppression on an LDDS test that really could be attributed to stress or non-adrenal illness.”

The vet never suggested to have an ACTH test done prior to starting Lysodren and I never asked for it as it was my understanding that all we needed was a LDDS in conjunction with the symptoms and the elevated ALP level. I even send all the blood test to Dr. Jean Doods for recommendations ….
Ok, now what do I do??? :confused:
Will the ACTH test next week help to get a definite diagnosis?
And here I thought I finally had most of my ducks in a row ……I need serious help here please. :(
Thanks,
Nathalie

frijole
06-06-2009, 04:06 PM
I think what Cushy was saying is that because the results were so borderline she would not assume it was cushings. There IS such a thing as a false positive on the test.

Cushings is often misdiagnosed. That is why most do more than one test just to be sure. The acth test would have told us the cortisol level. That combined with the ldds test would confirm the pdh dx.

You are set to have that soon right?

Kim

Squirt's Mom
06-06-2009, 04:17 PM
Hi Nathalie and a belated welcome to you and Phillip,

I got the same impression from Cushy's post as Kim did....concerned that the diagnosis may not be correct, and yet treatment was started.

If it were me, I would have two more tests done - an ultrasound on a high resolution machine, and full adrenal panel from UTK (which is the ACTH Cushy was talking about for the adrenal intermediate hormones.) The ultrasound is invaluable in my opinion and the UTK panel will let you know the cortisol level as well as any other hormones that may be elevated which will also cause the cush signs you have seen.

Please bear in mind these are our thoughts based on our experiences and knowledge, we are not trying to undermine your vet; how you proceed is entirely your decision and we will still do our best to help you regardless. :)

Hang in there!
Hugs,
Leslie and the girls

Nathalie
06-06-2009, 04:17 PM
Kim - yes, Phillip is going in for the ACTH test next week Thursday.
Nathalie

frijole
06-06-2009, 04:38 PM
Since Phillip exhibits signs of cushings I would continue on the dosage your vet has recommended but I would vigilently watch for signs of change as described in the lysodren loading link I provided earlier.

The protocol is very different (double normal loading standards but given once a week vs daily if I recall) and so it is unknown if it will even be effective but to be on the safe side - you must look for subtle changes in eating or water intake. If your dog eats like a pig like mine does it is easy - you look for changes in that. If your problem is simply water intake you must figure out a way to measure changes in that. I have 2 dogs and I measured their normal intake each day and looked for a reduction.

You probably have nothing to worry about. I just feel the need to point this out to be safe. If you get worried or see any changes call the vet, cease giving lysodren and move the acth test up.

Just keep us posted. We will see you thru this. Kim

ventilate
06-06-2009, 08:52 PM
Hi and welcome from me and mine.
I have to agree with the others about following the tried and proven protocols. It is so important, IMO. When vets wing it is when the dogs tend to get in trouble and some have chalked it up to a complication of cushings, when it was a complication with inproper treatment. IMO you will end up doing a lot more stims with the protocol you are using. Cushy is great at interpreting test results she helped me more than I can say when we started our journey 3 years ago in March. Unfortunately to do the U of Tenn panel I believe you will have to stop the lysodren for some time before the test can be run. Others here that had it done can tell you more about it.
I also wanted to comment on the hypothyroid, it appears your dog is truly hypo per your test results. Your vet is correct in that The T4 test, if that is low in a cushings dog it may be due to the cushings. My dogs T4 was low and it was due to the cushings, you can find out for sure by running the Free T4 ( your panel has the Free T4) if that one is low it is truly low, and not due to the cushings. my dog went for another year before her Free T4 went low and we had to begin treating.
I am sorry you are where you are right now. You may be better off and find it less expensive in the long run and maybe the short run to find an Internal Med specialist to treat your dog. they are the experts in Cushings and can get to the nuts and bolts of what is going on with your dog. If you are close to a university you may be able to get IMS appts for reasonable price. I know this is a lot to take in, and as others have said none of us are vets, only people that have dogs with cushings and want to share our experiences to prevent others from maybe making the same mistakes we have made and preventing their dogs from going through some of things some of ours have.
Good luck, and please keep us in the loop.
Sharon

Nathalie
06-06-2009, 09:32 PM
Please don’t get me wrong I truly appreciate all the input, suggestions and recommendations! It gave me a lot to think about and I do have to admit I had a minor meltdown earlier on :o because this has been such a long journey so far and my dogs are everything to me and I have done so much legwork on my own that at this point I thought I could relax a bit and let the vet call the shots for once. :rolleyes:
I have had many sick foster dogs in the past, epi, bladder stones, HW+ etc., but it is very different and very hard not to get emotional at times when it is one of my own dogs that is not doing well.

Anyhow, I am better now. I regrouped, re-read all the posts and the game plan is to give Phillip his last dose on Wednesday, do the ACTH test on Thursday and take it from there.

At that point I am going to ask the vet to reevaluate the tests “because the results were so borderline “ in conjunction with Phillip’s symptoms. I do not want to change vets again and start all over again at this point in time – I think she will work with me on this, I hope.
Cushy, I am going to read up on Atypical Cushings and follow the 2 threads you posted in case it turns out that he is not PDH. Again, thanks so much for responding in such great length and detail.
If the diagnosis remains PDH I think I am going to push for daily loading unless the vet feels that Phillip can not physically handle it and would cause harm. If we are going to load I will take a week of vacation in order to be around all day – I am due for some time off anyways.

Kim, Phillip eats everything that does not eat him first so I think I should be able to recognize once the Lysodren kicked in. I walk my dogs in a conservation area and yesterday he ate a dried out frog, half rotten baby snake and a dead baby bird :eek: – that’s how hungry he is all the time.

I will keep you all posted and thanks for all your support and encouragement – it really does help a lot.

Nathalie

acushdogsmom
06-06-2009, 09:49 PM
Hi Nathalie,

Your plan sounds pretty good to me. After you have the ACTH stim test results, you'll at least know where the cortisol production is and you'll be able to put things into perspective better and you'll also have a better idea of how you should proceed from there.

The best thing you can do is to become as well informed as possible and I'm glad if you are motivated to learn what you can about "atypical cushing's" too. (even if it turns out that you don't really need to use any of that information)

Hang in there. Give your crew a bunch of hugs from me. (I saw the pictures ... they are all adorable!) And remember that we're hanging in there with you, too. :)

AlisonandMia
06-06-2009, 10:12 PM
Hi and a belated welcome from me too.:)

I don't really have anything to add except to say that I can really relate to the eating everything in sight thing.

When she was actively Cushingoid, my Mia would consume anything that was vaguely carbon based. Here in Queensland, Australia (climate pretty much like Florida) we have cane toads unfortunately and there are always bits of sun-dried road-kill toad along every roadside and in every gutter and I was too afraid to take her out at all for fear she would chow down a bit of this before I could stop her - cane toad skin is deadly poisonous. Most dogs at least by the time they are adults instinctively know not to touch this stuff but Mia would undoubtedly have gone for it when her cortisol was high.

Like Phillip, Mia broke some teeth - I don't think it was because her teeth were particularly fragile or anything it was just that she "attacked" her food, including bones or chews of any kind with a sort of crazed kamikaze enthusiasm. She was so hungry that she just lacked any sense of self preservation when it came to food and eating and just wanted to get it into her stomach as rapidly as she could. When she ate her normal food it looked like she was trying to eat a hole in the bottom of the bowl - I've never seen another dog eat like that despite owning a succession of real food-pigs, including a beagle.

She even caught and ate a rat. She was already a keen and skilled ratter - it was in her genes - but she would never have dreamed of eating one of the filthy things and would always walk away in what looked like disgust once the rat was dead. When she ate that rat it was down her throat within 20 seconds of her getting it in her jaws which considering she was a tiny little thing - only 9lbs - was quite a feat of ingestion. I couldn't intervene although it was my first impulse as (a) I would have failed anyway as she was eating it way too quickly and (b) I might have lost a finger in the process (not aggression just by accident).

I think that when they are this hungry (and not all Cushing's dogs are quite this bad) that they must be really suffering as they truly feel they are "starving" all the time. They are also at considerable risk of ingesting something really dangerous or even deadly or even choking.

Mia was treated with Lysodren as per conventional loading (fortunately her diagnostics were really clear) and it was indeed very easy to see when she was loaded as her appetite became normal again - and everyone, especially her, was much, much happier!

Alison

frijole
06-06-2009, 10:40 PM
Nathalie,

It has been 3 yrs but I still remember my first thread was entitled "New, Frightened and Overwhelmed". I just wanted someone to tell me what to do! :p I hated the fact that I had to read all the medical stuff but it enabled me to have a conversation with vets and "take charge" of my dog's care.

You are well on your way. I think your plan is fine. The main thing you want is to make sure that your dog has pituitary cushings. If so then you can have the conversation with your vet. If it isn't then you can test for atypical cushings. Did your vet originally start out with a blood panel? That's how most of us discovered there might be issues. Knowing those values sometimes helps.

Anyway, meltdowns are totally allowed here and we have all had them. Then we pick ourselves up and hug our dogs. :p You wil be fine. And we will be here too.

Loved the story about Phillip's appetite. I can relate. That will certainly be easier to monitor than the water. Hang in there and welcome aboard. Kim

acushdogsmom
06-06-2009, 10:47 PM
Just wanted to add that a voracious appetite is a hallmark symptom of Cushing's. There are some Vets who don't even want to treat the dog, in spite of Lab tests that are all consistent with a Cushings dx, if the dog doesn't also have a voracious appetite.

And the first sign that most people notice that the Lysodren may have brought the cortisol to low enough levels is when there is a decline in the appetite. Watch how he eats every meal. That's what I did.

When you get the ACTH stim test results back and if the post-acth cortisol is higher than normal, even after having taken the 6+ doses of Lysodren, that kind of result plus the big appetite (and the LDDS test result where he never did actually suppress to less than 10 nmol/L and the cortisol did start to climb back up a bit from the 6-hour to the 8-hour mark) would pretty well clinch the Pituitary Cushings dx for me.

Not saying that it has to be a high post acth stim test number, because the Lysodren may have already brought the cortisol production down, but if it is high, and wityh the rest of what I just mentioned above, I think that would be a clincher for me. :)

Get some sleep tonight and we'll see you here again soon and often, I'm sure. ;)

Squirt's Mom
06-07-2009, 11:41 AM
Hi Nathalie,

A meltdown, huh? Well, you are now an official cush mom and member of this exclusive club! :p By the way, we have our own little looney bin here; if you ever feel the need, just holler and I'll scoot over for ya! :D

If our old thread were still around, I could direct you to mine and you would see what a total basket-case sounds and looks like. :eek: A friend of mine said she had the image of a woman who had stuck her finger in a light socket with her hair standing on end...she kindly left out the bulging eyes, bared teeth, and flying slobber! :o:p Nothing I read or was told made any sense...it might as well have been in a foreign language! But these wonderful folks here took me in and gently led me along until I could begin to understand a little bit. The more I learned, the calmer and more confident I became. Sane? Never, but a bit calmer. :p

Cushy is absolutely correct when she said the best thing you can do is become educated on this condition. You are Philip's only voice, his first and last defense, his advocate. The more you know the stronger you will be in these roles and the better off Phillip will be. Our Resource section has a great deal of info to offer on many related topics, including Atypical. So read all you can, as you have been doing, ask lots of questions and we will do our best to help you understand. You don't have to take this journey alone from here on out.

I am so glad you and Phillip are here and hope to learn more about the both of you in the future.

Hugs,
Leslie and the girls

PS. The story of Phillip eating all that awful stuff on his walk is funny and reminds me of my Squirt. She has always been a piggy and will eat anything that stays still long enough for her to grab. We made numerous trips to the vet over strange things she decided to eat. Once I was poisoning weeds with ammonia nitrate; I dropped a handful on a weed and Squirt gobbled it right up!! :eek::eek::eek: She was less than a year old at that point and this wasn't the first nor the last frantic trip we made to the vets due to her eating.

Nathalie
06-07-2009, 06:24 PM
I am so glad I found you guy’s and I am blown away by how kind and caring you all are. :D:D

Kim,
Yes, the first I had done was a complete blood panel. The thing that stuck out at me at the time was elevated and very high liver enzyme readings. When I asked Dr. Jean Dodds about it this was her feedback:” his liver function issues are not from liver cell injury -- as the ALT, which is the only liver-cell specific enzyme, was not very high for his age. the problem is with the very high ALK [ this is what's termed a "dump" enzyme -- as it reflects the excretion products of liver cell metabolism -- when the liver cells are working faster, they make more of this enzyme].
Very high levels often point to an overactive adrenal gland metabolism ……”

Food has always been very important to Phillip, but since he is ravenous all the time finding food has become almost his sole interest in life. Dinner time is now even stressful to him since he can’t get it into his mouth fast enough and there is never enough food to satisfy him. I am already feeding him about 30% more then usual but his body does not seem to be able to really utilize it as the amount he poops is too much for the amount he is eating.

I will let you all know the outcome of the ACTH test as soon as I get the result back.
I have read many success story’s about older dogs perking up again and feeling better once regulated and I can’t wait to report improvements.

Thanks again,
Nathalie and Phillip

acushdogsmom
06-07-2009, 06:31 PM
I will let you all know the outcome of the ACTH test as soon as I get the result back.

I have read many success story’s about older dogs perking up again and feeling better once regulated and I can’t wait to report improvements.Well, here's another story for you. :)

My Bichon was about 10 years old when diagnosed with Cushing's. He had almost every symptom in the book and was a very sad looking and feeling little dog, hair thinning, not able to climb stairs anymore, reluctant to go for walks, eating everything he could find to eat, pot belly, pee accidents in the house, etc ... plus very elevated liver enzymes and other "cushing's markers".

Fast forward to just weeks after starting treatment and with his cortisol sufficiently lowered ... his liver values were back to normal, his appetite and water consumption was back to normal, no more pee acidents, his activity level was back to normal and his hair was already starting to grow back in (although it did get a bit worse before it got better).

Within a few months of starting him on the Lysodren, his thyroid numbers were back to normal (with no thyroid treatment at all) and so were all of his other CBC and chem test results, and honestly, you couldn't even tell that there was anything wrong with him at all. His coat was full and thick again, he was acting like a puppy (well, years younger than his real age anyway) and we were amazed.

He lived for another 6+ years, with an excellent quality of life.

Here's hoping that you see all kinds of improvements soon, too. :)

StarDeb55
06-07-2009, 06:35 PM
Nathalie, just to give you another success story. My 1st cushpup, Barkley was diagnosed when he was about 7. He had most of the typical symptoms except for skin/coat issues, & muscle wasting. He was successfully treated with lysodren for just about 8 years, crossing the bridge at 15 from a medical issue not related to Cushing's.

Debbie

Nathalie
06-12-2009, 06:52 PM
Hi again,

Time for an update on my Phillip.

Just got the ACTH test results back and we also did a T4 test since I am not seeing any improvement in his appetite (maybe it so minute that I am just not noticing it) but I think that it may increased. I am not sure anymore what I am looking at anymore – probably been looking to much, to hard for too long.

ACTH test result:

Cortisol (0hr) 116 15-120 nmol/L
Cortisol (1hr ACTH) 266 220 -550 nmol/L
Cortisol (2hr ACTH) 326 220 -550 nmol/L

Thyroid:

T4 19.0 15.0 – 51.0 nmol/L

Vet said that Cortisol level is good ‘smack in the middle’ and to put him on a 1500 mg Maintenance Dose per week of Lysodren.
Thyroid looks good and keep on giving 0.4 mg Thyro-Tabs

Since he is still so hungry etc. and his glucose was elevated in February we also did a glucose test – will get result tomorrow. Vet thinks that he may have become diabetic.

When we did the Low Dose Dex test his Cortisol (0hr) was 167 and when we did the ACTH test his Cortisol (0hr) was 116 …
Can I compare these 2 numbers and based on the decrease conclude that the somewhat unusual ‘double maintenance dose’ worked or am I comparing apple and oranges?

When Dr. Jean Dodds ran the full Thyroid panel the T4 was ..

T4 ¯ ¯ 0.60 0.80 – 3.80 g/dL

X Thyroid levels are below expectations for a healthy geriatric (at least 1.0 µg/dL for T4 and 0.7 ng/dL for FT4).
I am confused by the different measurement used between the 2 thyroid tests – could someone please explain to me how I can compare these 2 numbers?

Also, 15.0 – 51.0 nmol/L seems to be a pretty large range and Phillip seems to be at the lower end of it – perhaps increasing his thyroid meds might be a good idea? Just because it is within a ‘normal’ range does not necessarily mean that this is a good number for Phillip??

What do you guy’s think about all this?

Thanks,
Nathalie

AlisonandMia
06-12-2009, 08:36 PM
Hi,

I think I know what the "problem" is - that is why you are not seeing any improvement in the Cushing's symptoms despite the "good" numbers.

It seems your results are in nmol/l which means that to convert them to ug/dl they need to be divided by 27.59. This means that Phillip's numbers are:

Cortisol (0hr) 4.2 ug/dl
Cortisol (1hr ACTH) 9.6 ug/dl
Cortisol (2hr ACTH) 11.8 ug/dl

(Ug/dl is the units of measurement most usually used in the US - although I'm in Australia and all our test results come in nmol/l I still find it easier to do the conversion as it gives smaller, easier-to-remember numbers).

Now the thing is, those would be great numbers for a normal, healthy dog - that is a dog without Cushing's but the numbers that are aimed for in a Cushing's dogs are necessarily considerably lower than those of a normal dog.

The reason for this is as follows:

In a normal dog (or person for that matter) the pituitary gland only puts out ACTH (which "tells" the adrenals to make cortisol) at certain times of the day and during times of stress. Typically, if we start the 24 cycle at midnight, the pituitary is not putting out any ACTH and the adrenals are not producing any cortisol at that time. Over the next 8 - 9 hours the amount of ACTH being produced and therefore the amount of cortisol being produced increases steadily until the daily cortisol production hits it peak at about 9am - it then decreases slowly and steadily until around midnight when it is at it its lowest point and the cycle starts up again.

However when a dog has pituitary Cushing's the ACTH producing cells in the pituitary tumor don't behave in the same way as "normal" pituitary gland cells. They don't switch off as and when they should and are generally a lot more active and produce an awful lot more ACTH and so in any 24 hour period a much larger dose of cortisol is pumped out by the adrenals - and this is what produces the signs and symptoms of Cushing's.

The aim of treatment with Lysodren is to erode away enough of the adrenal cortex that the adrenals just physically can't produce too high a dose of cortisol for the body every day despite what the ACTH the pituitary tumor is putting out is "telling" them to do. For most dogs with PDH this means that the peak cortisol-producing capacity of the adrenals (as measured by the post number on an ACTH stim test) has to be kept much lower than normal -somewhere between 1.5 and 5 ug/dl. Many, many dogs do best with their post on a stim test at around 3.2 although it is an individual thing and some are best with it towards the lower end of the range and some need to be at the higher or even a bit above 5 - it depends on the individual and can even change with age and other health issues.

If your vet is using "normal dog" readings as her goal in therapy then this would explain why she has had what she regards as good results from basically not loading. However I would think that many, if not all, dogs so treated would still be pretty symptomatic because their adrenals are still able to produce more cortisol than is healthy for them. This is almost certainly why you have not seen any improvement in Phillip's appetite - my dog was still fully symptomatic (with raging voracious appetite) when her numbers where around where Phillip's are now (we had a very long load (:eek:) and needed to do a stim test after 8 days and this was when her numbers were at that level). Once her numbers were (finally) within the correct treated-Cushing's dog range her appetite went back to what is normal for her and all her Cushing's symptoms rapidly abated.

Testing for diabetes is, however, a good idea especially if Phillip's BG was elevated in the past. Can you tell us what the number for the glucose was at that time? If he is tending to show elevated glucose then that is probably all the more reason to really get his Cushing's under control with the daily dose of cortisol he produces for himself at a more healthy level which means he needs to have a post stim result of somewhere between 1.5 and 5 ug/dL. (approx 40nmol/l - 138nmol/l).

This page here: http://listserv.tamu.edu/cgi/wa?A2=ind0203&L=cushings-pets&P=R19896&D=1&H=0&O=D&T=1 is really good. It not only sets out how to do the conversion between nmol/l and ug/dl but also goes into the what numbers (normal-dog -v- treated-Cushing's-dog) need to be aimed for in.

Alison

Nathalie
06-12-2009, 10:29 PM
Hi Allison,
Thanks for taking the time to respond in such detail – great link :D

“For most dogs with PDH this means that the peak cortisol-producing capacity of the adrenals (as measured by the post number on an ACTH stim test) has to be kept much lower than normal -somewhere between 1.5 and 5 ug/dl. Many, many dogs do best with their post on a stim test at around 3.2 although it is an individual thing and some are best with it towards the lower end of the range and some need to be at the higher or even a bit above 5 - it depends on the individual and can even change with age and other health issues."

I think I understand ….

His pre number of 4.2 ug/dl is not bad but maybe still too high but his post 2hr of 11.8 ug/dl is more then double the amount of cortisol a Cushings dog should produce in order to call the Cushings controlled and the dog ready to go on a Maintenance dose and since he is producing cortisol 24hrs non-stop this number may even rise over the course of 24hrs. These days Phillip is getting stressed way more easily, just the prospect of food puts him in a stressed out state adding to the problem.
So in a Cushings dog the pre and post numbers need to be between 1.5 and 5 ug/dl pre/post.

This would totally explain why I am not seeing any improvements at all – yikes, I am so glad you explained this to me.

But I am not understanding why the vet does not know that in a cushings dog the numbers have to be between 1.5 and 5 ug/dl (pre/post). What if I would not do my own research and seek the help of others, such the people in this group in getting my Phillip properly treated??? :eek:

Before the test result came back I told her I wanted to load if the result showed it needed to be done and she was sure that Phillip could handle it. She agreed to load if needed.
Any suggestion on how I am going to tell her that even so she thinks the numbers are great we need to bring them down to 1.5 and 5 ug/dl (pre/post) and therefore need to load? I am dreading this conversation. This vet has been really nice to me and Phillip but I am just wondering how she is going to monitor/treat Phillip with me if I have to double-check everything. This is serious stuff – and as you mentioned Allison we need to bring the cortisol down asap. I have also noticed more weakness/shaking in his hind legs and even a bit in his front legs in the past week. What would you guys do in a situation like this? Yes, I could switch vets, but who knows how this will turn out and what really know about cushings.
This is very discouraging.

Phillips Glucose was 7.3 Ref. range 3.6 – 7.0 back in February.

Just wanted to add, that if I did the math right, Phillips T4 would be still too low.... am I correct?
It went from 16.554 nmol/L to 19 nmol/L but according to Dr. Jean Dodds it should be at least 1.0 µg/dL for T4 (27.59 nmol/L) for a healthy geriatric dog.

Would you guy's increase the thyroid meds at this point from 0.4 mg to perhaps 0.6 mg every 12 hrs?
Thanks,
Nathalie

frijole
06-12-2009, 10:43 PM
Nathalie,

I agree, our dear Alison has such a nice way with words doesn't she? :p She makes it so much clearer. You got the message. Just note that the goal is to get the 2nd number between a 1 and a 5. The first number on the acth is usually not important so we'll focus on the 2nd one for now ok?

We have seen it before where this happens with vets and it's one of two things - either the vet is not experienced in treating cushings or out of "habit" is thinking that "normal" is that of a normal dog. Normally the labs that actually do the tests will differentiate to prevent this.

Anyway, I do agree that you need to discuss this with her. It is totally your call. If you feel that she is willing to learn and get up to speed then fine. If you are concerned she is over her head then... your call.

I think going to the resources section and printing out a few pages by the specialists that really specialize in cushings would help. That way she won't think you found advice from some whacked out internet group that doesn't know what they are talking about. ;)

These vets do attend seminars. Even mine in small town Nebraska attended one on cushings presented by Feldman who I really respect.

In the end you are the boss and it won't be easy... but you are simply being your dogs' voice in this. And by the way, you are doing a wonderful job.

Hugs
Kim

AlisonandMia
06-12-2009, 11:11 PM
This might be a good one to arm yourself with:

http://www.idexx.com/animalhealth/analyzers/snapreader/testmenu/cortisol/mitotaneprotocol.htm

and this is it in pdf for ease of printing:

http://www.idexx.com/animalhealth/analyzers/snapreader/testmenu/cortisol/mitotane.pdf

and this one's good too: http://www.k9cushings.com/forum/showthread.php?t=207

and this one: http://www.showdog-magazine.com/medical/cushings.htm

This one is particularly good: http://www.k9cushings.com/forum/showthread.php?t=199

Hope this helps.;):)

Alison

Nathalie
06-12-2009, 11:27 PM
I can not thank you guy's enough!!!

Since I have to pick up the Glucose test results tomorrow morning I will to have a talk with Phillips vet. :(

I will keep you posted. ;)
Nathalie

acushdogsmom
06-12-2009, 11:33 PM
Nathalie,

The showdog link that Alison gave you is actually information originally posted on the Auburn Endocrine Diagnostic page. See here for a bit of explanation on that:

http://www.k9cushings.com/forum/showthread.php?t=196

Alison also gave you the link to where you can find entire chapter on Cushing's from the Textbook of Veterinary Internal Medicine as a reference...

Dr. Edward Feldman, In S.J. Ettinger and E.C. Feldman (eds.) Textbook of Veterinary Internal Medicine, 1995, Chapter 118, Hyperadrenocorticism,

Here's the exact quote to look for there:

Goal of Therapy


The goal of therapy is to achieve an ACTH response test result suggestive of hypoadrenocorticism.

In our laboratory, successful response to Lysodren therapy is indicated by pre- and post ACTH plasma cortisol concentrations of less than 5 µg/dL

And Idexx Labs are now in Canada too ... they bought out "VitaTech" a couple of years ago. So your Vet should also be able to verify that reference.

And maybe your Vet would also be willing to consult with an Internal Medicine Specialist Vet, maybe an IMS at the Veterinary College in Guelph?

My IMS Vet used to often confer with GP Vets and told me that one of the most common things she had to "straighten them out on" was how to keep a Cushing's dog well controlled (and what ACTH stim test results you really need to try to aim for, to get good control of the chronic cortisol production). On the other hand, I guess some GP Vets don't like finding out they may have been doing it all wrong for some time ... so it's a bit tricky. You should be able to print out the veterinary references and show them to your Vet though. And you can also add that you have some friends who are telling you that their Cushing's dogs were well controlled for years at those lower-than-normal numbers. That would be true. I'm one of them! :D

Nathalie
06-13-2009, 01:12 PM
I did it!!!!!! Well, I should say WE did it!!! :D:D:D

Just spoke to Phillip’s vet, she could not see me but called me at home. I had all my resources up on the pc slowly turning into a nervous wreck while waiting for her to call me.

I explained that I checked Idexx Labs website and confirmed their info with Dr. Edward Feldman, In S.J. Ettinger and E.C. Feldman (eds.) Textbook of Veterinary Internal Medicine, 1995, Chapter 118, Hyperadrenocorticism.
At first when I talked about the Dosing and Monitoring protocol from Idexx and said that on Phillips test the ‘normal’ cortisol range is NOT for a dog on Lysodren but for a ‘normal’ dog she said that she would call the lab on Monday and that the lab should have listed the target range for a dog on Lysodren and not a ‘normal’ dog to confirm that my calculations are correct. ;)
I then explained that the conversion I did is correct and referred to Dr. Feldman after that she was super nice and agreed completely that his numbers are not good and that he truly does not present as being controlled.
I am starting to load tonight, she will get more Lysodren ready for me and inform all staff what is going on with Phillip so everybody is aware about what we are doing. :)

Then I talked about his T4 being still too low at 19.00 nmol/L according to Dr. Dodds who would like to see him at a minimum of 27.59 nmol/L.
She agreed to up his thyroid meds from 0.4 mg to 0.6 mg.

In a way this just blows my mind…… It seems like she did not even look at the actual numbers, just read that according to the lab the numbers where in whatever the lab thought to be the ‘normal’ range without spending a second thought about it…… :(

The Glucose test came back within normal range.

Fructosamin 264 180 – 350
Hemolysis 2+
Icterus Normal
Lipemia 4+

While walking the dogs this morning I ran into friends of mine that know and love my guy’s and had last seen Phillip 2 weeks ago – they too noticed a decline in the way he looked, especially his hind end weakness, so much time wasted to finally get to the point of truly loading him.
I am also hoping that upping his thyroid meds will make him feel a bit better.

Now I am freaked out about loading – yikes. I have the prednisone ready and will be watching him like a hawk.

I can’t say it often enough how truly grateful I am for all of you who helped getting me the information needed to hopefully get Phillip on his way of feeling better.

Nathalie

frijole
06-13-2009, 01:35 PM
Nathalie,

I am so proud of you! It is never easy to confront a vet with errors but you do learn alot about your vet. ;) Yours was willing to make adjustments. It is when they don't that you know it is time to move on.

We see the errors on the lab reports often which is why I mentioned it earlier. I agree that an experienced and/or attentive vet catches the lab's mistake but perhaps it was a stressful/crazy day... we never know. I have to admit that my dog's cushings has taught me to track and double check everything regarding my health as well.

So you are on your way to a traditional load. Just to be safe... could you share with us the dosage amount? If I recall while you were not giving it daily the dosing amount was higher than the recommended daily dose. So let's just be safe and check. The recommended daily amount is between 25 and 50 mgs of lysodren per kg of weight.

If you want us to check the math - just give us weight and the amount you are planning on giving daily. Monitor the food intake (speed with which it is inhaled :D) and look for subtle changes. You also could watch the poop... isn't this fun?... for changes. You don't want diarrhea. That and vomiting are signs of too much lysodren.

So don't give any new foods or alien treats while loading because then you won't be sure what causes changes. I wrote a log daily and it helped my feeble mind thru this.

You will be just fine. You did the hardest thing this morning. Again, proud of you girl! You are a "pro" now.

Kim

acushdogsmom
06-13-2009, 02:32 PM
Really glad to hear that your Vet didn't take offence at your having done some "research". She must have been impressed to hear you quoting IDEXX protocols and Feldman in particular (he is world renowned in his field).

Some Labs do actually give both reference ranges on a Lab report ... i.e. for diagnostic purposes (the normal reference ranges) and for dogs who are in treatment for Cushing's. But most Labs don't ... they only give the normal reference ranges. I was actually surprised when a member posted a couple of years ago that her Lab report copy specifically mentioned that the dog (hers) was in treatment and that the normal references ranges do not apply, and then they went on to give the reference ranges we look for in a treated Cushing's dog.

As for the loading ...

The ACTH stim test results that you just got were:


Cortisol (0hr) 116 nmol/L (4.2 ug/dl )
Cortisol (1hr ACTH) 266 (9.6 ug/dl)
Cortisol (2hr ACTH) 326 (11.8 ug/dl)

I don't think you're going to need to load for very long to get the post ACTH number down to less than 5 ug/dl or 110 nmol/L (less than 110 nmol/L is exactly where my Vet liked to try to keep our dog's numbers, by the way)

There's no way to really know how quickly any particular dog's adrenal cortex will erode in response to the Lysodren. Some load very quickly and others take much longer. And since you have no idea what the before-any-Lysodren-was-given ACTH stim test numbers were (because there was no pre-treatment ACTH stim test done), you still don't know whether Phillip is a fast or slow responder.

I would say, as for knowing when to stop the Lysodren, watch how he eats his meals. Give him half of his meal or three quaters of his meal, and if he eats it enthusiastically, give the Lysodren and then the rest of his meal. If he hesitates in any way or eats the first part of the meal slowly, don't give the Lysodren and cxall the Vet. It's probably time to do the ACTH stim test to check where the post-ACTH cortisol number is.

Read the Lysodren Loading Instructions (these are from the Textbook of Veterinary Internal Medicine)

http://www.k9cushings.com/forum/showthread.php?t=181

Print them out and keep them handy. :)

You can't use any of the pre/resting cortisol numbers for reference ... even if the LDDS and ACTH were not completely different tests, the pre number can vary depending on things like how stressed or relaxed a dog happens to be when they draw that blood sample. Only the post-ACTH numbers can tell you how much cortisol is left in reserve in the adrenals. And that's what you need to know --- the capacity for cortisol production, which can be determined by how much cortisol is being held in reserve in the adrenal glands. And the ACTH stim test forces the adrenals to release their cortisol reserves into the bloodstream, where we can then measure it.

By the way, I don't know how your Vet calculates the cost of an ACTH stim test, or if the Lab possibly charges her more for evaluating three blood samples vs only two blood samples, but most Vets do not take three blood samples for an ACTH stim test anymore. Two samples is enough ... one "pre" and one "post" sample.

The timing of the second blood sample draw depends on what kind of synthetic ACTH your Vet uses to do the ACTH stimulation test. If it's "Cortrosyn" or "Synacthen", then the second blood sample can be taken one hour after the injection of the synthetic acth is given.

If it's "ACTHAR gel", then the second sample should be drawn at two hours after the injection is given.

But you don't really need to take three samples. :)

It might actually save you some money to have only two samples taken, and also, with only one post-ACTH stim test number being reported (rather than two post numbers) you won't have to wonder which post number to look at, to tell you if your dog is within the desired cortisol production range. :)

My dog's ACTH stim test numbers always came back as the 0-hour sample and the 2-hour sample, but we (my Specialist Vet and I) knew that the two hour sample was really a one-hour post injection sample. It doesn't matter the exact time that the Lab thinks the second sample was taken, it only matters that we know when it was really taken and that it was taken in accordance with the instructions for the specific kind of synthetic ACTH that we used to cause the stimulation.

Roxee's Dad
06-13-2009, 03:09 PM
Nice job Nathalie, You truley are the voice and advocate for Phillip.



Now I am freaked out about loading – yikes. I have the prednisone ready and will be watching him like a hawk.

I am sure you will do fine:)

I am happy for you and Philip and, for your vet for getting a free education update.;) So glad she was willing to discuss openly with you. It makes a world of difference when you and your vet work together as a team.

Nathalie
06-13-2009, 04:39 PM
So you are on your way to a traditional load. Just to be safe... could you share with us the dosage amount? If I recall while you were not giving it daily the dosing amount was higher than the recommended daily dose. So let's just be safe and check. The recommended daily amount is between 25 and 50 mgs of lysodren per kg of weight.

Kim

Phillips weight is 63.4 lbs or 28,76 kg.
I am suppost to give him 1500 mg of Lysodren daily until loaded.
So about 50 mg per kg.

Forgot to add - I was planning on giving him 1500 mg tonight and starting tomorrow split the daily dose up between breakfast and supper eg. 500 mg in the morning and 1000 mg at night.
Does this sound ok?

Nathalie

BTW: I am not sure I am feeling like a 'Pro' yet but it sure has been a steep learning curve since yesterday night :)

acushdogsmom
06-13-2009, 04:55 PM
It's a little bit over 50mg/kg/day, but the total daily dose sounds okay to me and I like the idea of splitting the dose too. That's how I did it. :)

Mine was one of those who was very very sensitive to the Lysodren, which turned out to be a good thing because we were able to keep his cortisol in the desired range (long-term) with less than the usually needed amount of Lysodren.

He loaded fully (from a very high post-acth number to almost too low) in only three days! Only sign I saw was that he looked up at me during a meal when I said his name, which was not something he ever would have done while his cortisol was way high, so I knew the cortisol had dropped.

I was glad when I saw the sign, that I'd only given him half of that day's dose so far.

edited to add: P.S. Although his appetite lessened as soon as the cortisol was low enough, my dog's water consumption only went back to normal several weeks after the loading was completed. Every dog may be a bit different than the next one in the way they react to the drug, but appetite seems to be the first sign that people notice that the cortisol production is sufficiently reduced.

Nathalie
06-13-2009, 05:25 PM
Cushy,

Really glad to hear that your Vet didn't take offence at your having done some "research". She must have been impressed to hear you quoting IDEXX protocols and Feldman in particular (he is world renowned in his field).
Trust me, me too. I was up until 2 am last night getting my info straight and figuring out how to best word this so this all has a positive outcome. I basically blamed the lab for not using the right range which kept things non-confrontational.
It felt very good/impowering to quote these 2 sources (actually truly understanding it too) and once I mentioned Feldman I could tell she went from maybe a bit hesitant to very open and accommodating.


I don't think you're going to need to load for very long to get the post ACTH number down to less than 5 ug/dl or 110 nmol/L (less than 110 nmol/L is exactly where my Vet liked to try to keep our dog's numbers, by the way)
That would be nice and would save some $. Once I think he is loaded do we need to do the ACTH test the next day or do we have to wait a certain period of time after the last dose of Lysodren was given before we can do the stim test?


By the way, I don't know how your Vet calculates the cost of an ACTH stim test, or if the Lab possibly charges her more for evaluating three blood samples vs only two blood samples, but most Vets do not take three blood samples for an ACTH stim test anymore. Two samples is enough ... one "pre" and one "post" sample. The timing of the second blood sample draw depends on what kind of synthetic ACTH your Vet uses to do the ACTH stimulation test. If it's "Cortrosyn" or "Synacthen", then the second blood sample can be taken one hour after the injection of the synthetic acth is given.

In the beginning I was quoted $172.73 Cdn for the ACTH test but she actually charge me $139.50 Cdn. Not sure why the drop in price but I am not going to question it.;)
When I look at the invoice it states that she used Synachten. I actually questioned the two post blood samples when we went in to have the ACTH test done and when I mentioned that Idexx testing protocol only called for 1 sample she said doing the 2 will give more of a curve, hence provides more data......
Does the price for the ACTH sound about right? I am also still looking for a less expansive source to purchase Lysodren. The vet gives it to me at her cost which is $5.30 Cdn, but once he is loaded I will get it directly from a compounding pharmacy for $4.30 Cdn + $10 dispensing fee if I can find a more cost effective source.

Splitting up the Lysodren daily dose was my idea - I am learning:D
Thanks,
Nathalie

acushdogsmom
06-13-2009, 05:43 PM
Hey Nathalie! I see that you figured out the quote thing (they are called quote tags, actually). :D :D :D
Cushy,

Trust me, me too. I was up until 2 am last night getting my info straight and figuring out how to best word this so this all has a positive outcome. I basically blamed the lab for not using the right range which kept things non-confrontational.

It felt very good/impowering to quote these 2 sources (actually truly understanding it too) and once I mentioned Feldman I could tell she went from maybe a bit hesitant to very open and accommodating.It does feel good, to understand it and to know that you are quoting (and understanding) the protocols as put forward in the known and valid veterinary literature. :)


Once I think he is loaded do we need to do the ACTH test the next day or do we have to wait a certain period of time after the last dose of Lysodren was given before we can do the stim test?Well, when you are giving Lysodren daily (ie as a real loading dose) the effect of the Lysodren is cumulative. Not so much when it's a weekly maintenance dose, but when you are giving the Lysodren daily, it is cumulative. And the effect of the Lysodren can therefore continue for several days or so after you actually stop giving the drug.

My Vet also uses Synacthen for the stims, by the way, because she says it's as good as Cortrosyn but less expensive. Synacthen is what they usually use in the UK and Europe, Cortrosyn is more commonly used in the USA. (She doesn't the gel at all though)

She is an Internal Med Specialist and she prefers to do the stim test a couple of days after the loading is stopped if possible. That way the test result shows the full effect of the Lysodren loading doses.

(When you're in maintenance dosing, the timing of the stims doesn't really matter.)

It isn't always possible to wait though ... like when it is suspected that the dog may be overdosed for example.

You also don't want to do a stim test within 24-48 hours of having given prednisone because pred "reads" as cortisol on the stim test results. And since you can't tell which part of the result is cortisol and which is pred, you can't know for sure how much cortsiol is really being produced.

Sometimes they do have to do a stim within that 24-48 hour window even if pred has been given (again, in the case of a suspected Lysodren overdose for example) ... and the Vet can sort of make an educated guess regarding how much of that reported number is due to the pred because they do know the amount of pred that was given. But it's better to not have any pred in the system when you do the test.

The price of your stim sounds reasonable to me. Anything under $200 actually sounds like about what many pay for a stim. Mine were more expensive than that and I'm in Canada too.

re the Lysodren cost ... $5.30 Canadian sounds fair. But if you can get it for less and as long as you're sure it's the "real thing", go for it.

My Vet used to give me a prescription and I'd get it filled at a regular people pharmacy. The more pills I bought at a time, the less it cost per pill. So I used to buy it in bottles of 100. (the exp date was usually about 2 years in advance)

Nathalie
06-13-2009, 06:15 PM
Hey Nathalie! I see that you figured out the quote thing (they are called quote tags, actually). :D :D :D
Yep, and took me long enough I know. When I am not in ‘meltdown mode’ I usually can figure these things out a bit quicker. :D:D
Plus I wanted my posts to look as nice as everybody else’s.:o
Just in case anybody wonders why I can’t manage to get some of the spelling right and the grammar is ‘funny’ … English is not my first language, I am originally from Germany even so I have been here for years I just can’t hit the reply button, type a quick message and hit send – it’s a bit more difficult for me. Just thought I will mention this in case anybody was wondering. ;)

Nathalie

frijole
06-13-2009, 06:36 PM
Just wanted to tell you I had no idea English isn't your first language so don't think twice about that.

Like Cushy said earlier it may not take your dog long to load. We have seen that larger dogs seem to load faster than smaller ones. And you already had a little head start so... be vigilent. Of course you will.

I always fed my dog food first and gave the pill last just to be sure. Just remember, when in doubt - don't give the pill. You can't take it back and they continue to work for up to 48 hrs. Also don't give a sick dog (vomit, diarrhea) lysodren EVER. Be careful when handling it - wash the hands well. It shouldn't be used by pregnant women.

I wrapped the pill in cheese to coat the stomach when eating it. Cream cheese is real easy to roll into a tiny ball. Peanutbutter is another favorite among our cush dogs. :D

At first you will be scared but as the pill starts to work you will feel great about the drug. So we understand - and have been there. Best wishes. Kim

AlisonandMia
06-13-2009, 07:17 PM
I'm delighted to get up this morning and see that all has gone well and things are happening for Phillip.:D;)

Splitting the daily dose is a very good idea - particularly with a larger dog and one that may not have that far to go to be loaded. Most protocols call for the daily dose to be split into a morning and night dose. Although you don't have a pre treatment stim to compare with the fact that he is around 11 now suggests that he has had quite a significant response to the Lysodren (double maintenance) that he was on. I have a feeling he is going to load from here very fast.

One thing I would suggest though is that you split the dose evenly and give 1 1/2 pills in the morning and 1 1/2 pills in the evening. Lysodren pills are pretty easy to split into halves and even quarters - just wash your hands thoroughly (and/or wear disposable gloves) when handling it, that's all. I had to always split my dogs Lysodren into small portions (1/5's :eek:) and kept a blade specifically for that purpose and made myself a little black plastic cutting board out of an old document folder. Black was good because I could see every crumb.

Another little thing to be aware of with Lysodren is that the fat/oil content of the food it is given with can have a big effect on how well it is absorbed - the fattier the food the more is absorbed. Usually this isn't a big deal but it does pay to remember that increasing or decreasing the fat content of the diet can effectively increase or decrease the actual dose of Lysodren the dog is receiving - ie actually getting into it's blood stream. I had some minor glitches in Mia's treatment which I overcame by giving her maintenance doses with a standardized "lysodren meal" two hours clear of any other food to make sure that the fat content was always the same. I feed a raw/home cooked diet with quite a bit of variety so I really needed to do that if we weren't going to run into problems with what amounted to really inconsistent dosing.:eek:

Good luck and keep us posted!:) (I know you will!!):)

Alison

PS. I would never have picked it that English was not your first language. The only sign (in hindsight) is that you express yourself very clearly and that's something I have noticed with non-native speakers - it must be a reflection of the increased amount of thought that is needed to write in a language that is not your first language.:)

gpgscott
06-13-2009, 07:53 PM
Welcome Nathalie,

I have just read your story, you have been through a lot. But you did stick with it, educated yourself and it seems also your Dr. on the way and now on to treatment.

Please continue to post frequently, I am sure the loading will go fine because you are so attentive.

Good luck. Scott

Nathalie
06-13-2009, 08:29 PM
Kim, I am going to watch him like a hawk and if there is any doubt what I should do I just post.

Alison, I am feeding raw as well (Urban Wolf) – will need to see if I can figure out what the fat content is. Deviding his daily dose into equal doses sounds like a good plan.

Scott, thanks for the welcome. I feel like I been on a bloody rollercoaster since last September. But with the help of everybody in this group a pretty bad situation turned into something really good.

I certainly will post updates and who knows, the next crisis might be just lurking around the corner…. Just kidding :D:D:D . But I am not worried, because I know where I can get the support.
I belong to quite a few groups but I must say I never felt so welcomed and comfortable to post in any in any of these other groups as I do with you guy’s.
In short, I am here to stay and hopefully down the road, as I gain more experience with Cushings I will be able to assist someone else who needs help to get their dog better.

Everybody have a great Sunday, :)
Nathalie

acushdogsmom
06-17-2009, 01:32 PM
It's Wednesday, and I was just wondering how the loading is going? Any sign yet that the loading is complete?

Nathalie
06-17-2009, 07:49 PM
I was just going to send an update :)

No, I am not seeing a difference in his appetite. Today I think he is even hungrier if this is possible.
On the bright side he seems to be tolerating the Lysodren ok.

I am very concerned about all the muscle mass he has lost. Every week that passes he seems to be getting a bit weaker in his hind legs.
We also had a view warmer days and he had such a hard time. For this reason I take him only to places that have a creek or pond that he can use to cool off. When we get to the park, the first thing he does is get into the water and just stands there his hind legs trembling – it just breaks my heart seeing him like this. :(:(:(

Once he is loaded and the cortisol is down will the muscle loss stop right away?
Nathalie

frijole
06-17-2009, 08:44 PM
Hi Nathalie,

My memory of the hind leg "recovery" was that it was gradual. It seemed like 3 or 4 weeks into treatment I noticed "oh wow she isn't trembling or struggling anymore". So don't expect immediate results and of course none of them are the same. :rolleyes: Just know you are doing the best thing you can for Phillip and with time he'll be running around the house creating havoc and this will be a distant memory. Thanks for the update! Kim

Roxee's Dad
06-19-2009, 07:44 AM
Hi Nathalie,

Just checking in to see how Phillip is doing?

frijole
06-19-2009, 08:15 AM
Nathalie - me too. Whats up? :D

Do you have a date from the vet for an acth test? Remind me when you started loading again please... oldheimers disease here. ha. You might consider doing a test 7 to 10 days into loading just to find out where you are. Sometimes dogs need a higher than normal dose (my girl was one) and testing during loading can give you a feel for progress and if adjustments need to be made.

Don't read anything into my comments - just taking a cautious approach. No dogs are the same. Keep us posted and feel free to whine anytime you want. We can handle it all. :p Kim

Nathalie
06-19-2009, 01:18 PM
Thanks for asking about my Phillip!:):):)

He has not loaded yet, at least not that I can tell for sure. We started the loading last Saturday and since he already had quite a bit of Lysodren over the past month I thought I would be seeing sure signs telling me that he is done loading by now.
Yes, I agree that if I don’t see a decrease in appetite after 10 days or loading we probably should do a stim test again.

His thyroid level is still way too low which could make him extra hungry.
Do you guys think the low thyroid could make him hungry enough for me to notice the early signs of loading?
I would hate for him going too low because I missed the signs.
I upped his thyroid meds last Saturday from 0.4 mg to 0.6 mg 2x per day but assume it would take a while for it to kick-in

Kim, don’t encourage me to whine – once I get started I may not be able to stop again and since I am going to be off work for the next week I would have plenty of time to really get into it. :D:p:D

frijole
06-19-2009, 02:09 PM
:eek: Oh No - a whole week of whining ahead of us. ;)

Alot of dogs (mine included) have both hypothyroidism and cushings. You confused me a bit regarding your comment about your dog's thyroid "still" being low. Did you do more testing?

Read here for details on how sometimes cushings can cause hypothyroidism that goes away when cushings is treated. http://www.k9cushings.com/forum/showthread.php?t=191

In short - I don't think you would miss signs due to this. Just watch and look for slight things like "pausing while eating", "leaves a few kibbles" etc. That is enough of a change. Are you doing poop patrol? :D Now there's a way to spend vacation. :eek:

Keep an eye out for loose stools and/or vomiting. Either one - no more lysodren. You probably know that.

I just think you are close. I bet it happens over the weekend cuz that's how things work. I would plan either way on having the test done on Monday if you can get in simply because it has been 10 days.

Thanks for keeping us posted.
Kim

MiniSchnauzerMom
06-19-2009, 03:45 PM
Hi Nathalie,

Just checking in to see how Phillip's loading is going. So far, so good. Kim has given you the info you need and I've got nothing to add except....it's not whining....it's "expressing yourself" so welcome to the club....we're all members!! :D

Louise

Nathalie
06-19-2009, 06:22 PM
Alot of dogs (mine included) have both hypothyroidism and cushings. You confused me a bit regarding your comment about your dog's thyroid "still" being low. Did you do more testing?

Read here for details on how sometimes cushings can cause hypothyroidism that goes away when cushings is treated. http://www.k9cushings.com/forum/showthread.php?t=191

In short - I don't think you would miss signs due to this. Just watch and look for slight things like "pausing while eating", "leaves a few kibbles" etc. That is enough of a change. Are you doing poop patrol? :D Now there's a way to spend vacation
Kim

Last week when we did the ACTH test we also did a thyroid test.

Result from Dr. Dodds:

T4 0.60 0.80 – 3.80 ug/dL

Result from last week:

T4 19.0 15.0 – 51 nmol/L

When I convert from nmol/L to ug/dL I divide the nmol/L by 27.59 which would be 0.69 ug/dL.
Which means T4 only increased by 0.09 ug/dl within 1 month
Per Dr. Dodds healthy geriatric should be at least 1.0 µg/dL (27.59 nmol/L for T4
She also said “Optimal therapeutic response levels should be in the upper 1/3 to 25% above the upper limits of the resting optimal ranges at 4-6 hours post-BID thyroid medication.”
Does anybody know what this means translated into numbers?

What is the ‘monitoring range’ for T4? When I checked Idexx’s website (http://www.idexx.com/animalhealth/analyzers/snapreader/testmenu/t4/protocol.htm)the ranges are all different between Idexx website, the range they reference on Phillips T4 test result and Dr. Dodds.
If any of you had a 'monitoring' thyroid test done by Dr. Dodds what range did she use for the T4?

Dr. Dodds did recommend to put Phillip on thyroid meds even so the low thyroid could be due to Cushings. We can always stop or decrease the thyroid meds if needed.
She also said, and this is interresting because Phillips vet said that once on thyroid meds the dog has to stay on for life....
"many veterinarians believe incorrectly that once you put an animal on thyroxine, he/she needs to be on this medication for life. In fact, if you stop the thyroxine even after years of therapy, it takes 5-6 weeks for the pituitary-thyroid axis to be reactivated to its original capacity [whether low or normal] . "



Keep an eye out for loose stools and/or vomiting. Either one - no more lysodren. You probably know that. Kim

Well ..... his poops been a bit loose off and on for some time now. Are we talking something along the lines of diarrhea?


Hi Nathalie,

Just checking in to see how Phillip's loading is going. So far, so good. Kim has given you the info you need and I've got nothing to add except....it's not whining....it's "expressing yourself" so welcome to the club....we're all members!! :D

Louise
Louise, thanks for taking the time to inquire about Phillip.
‘Expressing yourself’ – I like that and its something I can be real good at. :D

Thanks,
Nathalie

BestBuddy
06-19-2009, 06:30 PM
Hi Nathalie,

Buddy had a low thyroid number and was put on medication months before the dx of cushings. We used trilo to treat cushings and once Buddy's cortisol levels came down he was able to stop the thryoid meds.

Jenny

frijole
06-19-2009, 07:35 PM
No I am not familiar with the monitoring you are doing for thyroid - that's why I brought it up... different! I'll be interested to see if anyone else here has done this.

Re the poop. You want to catch it BEFORE diarrhea. So somewhere between soft and runs. Can you believe this conversation? ;) I kept a stick handy. You might not need to do this but its a safety measure and I believe that is how I managed to pick a time for the last loading acth test. She was at 1.8 I think. Glad I poked.

AlisonandMia
06-19-2009, 07:55 PM
Another thing that crosses my mind is that Phillip is a collie/beagle mix. We have seen a few beagles overload (never seriously) because their appetite just keeps going even when they are, in fact, loaded. It seems to be a beagle thing - that "robust" beagle appetite just seems to keep them in "piggy" mode for a bit longer than would happen with many dogs.

I think it's possible that this softening poop could be a sign of loading - how long have you been seeing it and how unusual is it for Phillip to have softer poop? It may be best to stop the loading now and get another stim test done - the only real downside of doing this is the cost of the test but then again if you do overload then that could result in needing another test at some point anyway.

Alison

Nathalie
06-19-2009, 07:56 PM
No I am not familiar with the monitoring you are doing for thyroid - that's why I brought it up... different! I'll be interested to see if anyone else here has done this.

Re the poop. You want to catch it BEFORE diarrhea. So somewhere between soft and runs. Can you believe this conversation? ;) I kept a stick handy. You might not need to do this but its a safety measure and I believe that is how I managed to pick a time for the last loading acth test. She was at 1.8 I think. Glad I poked.

Re the thyroid testing – now I am confused – what do you mean by ‘different’? Am I making things more complicated then they really are? :confused::confused::confused:
Kim - How do you monitor thyroid levels?
So far all I have done is send blood to Dr. Dodds for a full thyroid panel , started thyroid meds 5 weeks ago, ran a T4 one week ago (same time as ACTH test) and increased meds from 0.4 to 0.6 mg 2x per day.

Re the poop .. Okay – I think I am getting the picture. :eek::eek:
Nathalie

frijole
06-19-2009, 08:30 PM
Nat, you mentioned something about your doctor's technique... mine, well it is simple. We tested when she got cushings, 6 mos after treating fr cushings and then once since. Don't fret. You know more about the thyroid then I do based on your posts. :D

Kim

Nathalie
06-20-2009, 06:46 AM
Another thing that crosses my mind is that Phillip is a collie/beagle mix. We have seen a few beagles overload (never seriously) because their appetite just keeps going even when they are, in fact, loaded. It seems to be a beagle thing - that "robust" beagle appetite just seems to keep them in "piggy" mode for a bit longer than would happen with many dogs. Alison

Alison, excellent point – Phillip has always been ‘big’ on food and I can’t remember when he did not eat his meals or anything else you handed him with GREAT enthusiasm. I think in the past 6 years there where only about 4 days where he did not eat his meals and that was when he had a bad GI issue.



I think it's possible that this softening poop could be a sign of loading - how long have you been seeing it and how unusual is it for Phillip to have softer poop? It may be best to stop the loading now and get another stim test done - the only real downside of doing this is the cost of the test but then again if you do overload then that could result in needing another test at some point anyway.

Alison

Well, his poops used to what I call perfect ‘pick-up quality’ but since we started the Lysodren there are a bit softer and there is also more of it. Every night we eat apples and usually Phillip is just as excited about this as about his dinner. BUT, for the past few days he is less ‘piggy’ about it and last night instead of just trying to eat the whole huge piece at once he took a bite …dropped the rest … chewed and took another bite. He also had a real soft mouth when taking the apple pieces last night. Usually he is real snatchy, still is with cookies but not with apples.
He gets his thyroid pill 1h before eating and I don’t have to wrap them in anything he just snatches them from my hand. This morning with a very soft mouth he took them but actually paused a bit and was not enthusiastic about it – I guess he took a second to figure it is nothing special but out of habit he still ate them.
For the past 2 nights he seems to be a bit restless too, I hear him moving from one spot to another till he settles down again.
Just gave him his breakfast and he is still eating very fast but did not run right into the kitchen when I opened the fridge and the container I keep the food in.
I did give him one more dose of Lysodren but I think you are right, its might be time to stop. I am going to try and get him in for a test on Monday.

I know that the ACTH should be done preferably after 48h post last dose to get the full cumulative effect if I am not mistaken.
IF his vet is not in on Monday should I insist that the other vet who works on Monday do the test in order to stay as close as possible within that 48h timeframe or would it be ok to test him on Tuesday?

Thanks,
Nathalie

frijole
06-20-2009, 08:38 AM
Good girl! No more lysodren until we test.

Your last pill was Friday... so Sunday is 48 hrs...Monday is preferable but Tuesday is not an issue. Can you phone this morning to set up a time? THat way you will know.

Assuming he is loaded you usually wait one week (from last dose) until beginning the weekly dosing. Most vets will do another acth test after 30 days and this is to make sure that load is being sustained. (dosage is right)

The restlessness you speak of is common with both cushings and hypothyroidism. I will give Haley some melatonin (she's 17 lbs and I only give her 1/2 of a 3 mg pill) to relax her. It works.

Kim

Nathalie
06-20-2009, 11:11 AM
Kim,

Just called the vet and he is going in for a stim Monday morning at 8 am and this time we are only going to do one post draw (after 2h) as per Cushy’s post. :):):) I do pay attention to what you guy's tell me. ;)
I am just hoping the numbers are bang on and not in the higher end or above.

I am going to look into melatonin once we know for sure that he is loaded and he continues to be restless once he has been on a maintenance does for a while. Milk thistle is also something I would like to get him started on down the road because his ALT was a bit high.

Nathalie

frijole
06-20-2009, 12:59 PM
Great! We will be waiting for the results. I am glad your vet is able to do it. Kim

MiniSchnauzerMom
06-21-2009, 03:33 PM
Nathalie,

Just dropped in to wish you well with Phillips ACTH stim test tomorrow. Keeping my fingers crossed for good results. Will be watching for your update.

Louise

Squirt's Mom
06-21-2009, 04:09 PM
Hi Nathalie,

Here's hoping the numbers come back good and show Phillip is loaded! I know you are ready for that to be over! ;)

Let us know how it goes!
Hugs,
Leslie and the girls

gpgscott
06-21-2009, 04:48 PM
Hi Nathalie,

Checking in here also to wish for a spot on loading.

Scott

Nathalie
06-21-2009, 07:44 PM
Thanks Guy’s, :):):)

Yep, it is time to get this over with.
The vet office called back on Saturday to reschedule for Tuesday ……. they ran out of Synacthen. Gee, why am I not surprised (last week they ran out of Lysodren). :rolleyes::rolleyes::rolleyes:
I will post an update as soon as I get back the result.
Cheers,
Nathalie

frijole
06-21-2009, 08:25 PM
Thanks Guy’s, :):):)

Yep, it is time to get this over with.
The vet office called back on Saturday to reschedule for Tuesday ……. they ran out of Synacthen. Gee, why am I not surprised (last week they ran out of Lysodren). :rolleyes::rolleyes::rolleyes:
I will post an update as soon as I get back the result.
Cheers,
Nathalie

Incredible. Is there a run on cushings dogs? ;) Nat, Tues is OK but don't let them move it back further because then you aren't getting a true read. Shame on them for not thinking ahead. Re lysodren, after paying over $8 US a pill from the vet I quickly found it online and saved 50%. I get mine from drugstore.com. They get the rx from the vet and even call to renew it when needed. I do nothing but reorder when out. Never had a single problem with them or the order. Not sure if being Canadian would slow things down or not but just sharing...

Thanks for telling us. And by the way - they will send the labs out for processing so you won't know the same day. Here it is a typical wait of a couple days. You might ask when you go in what is normal and of course call them to make sure they followup. :p

Meanwhile how is Phillip? Hugs Kim

StarDeb55
06-21-2009, 08:35 PM
Actually, a run on Cushpups might be within the realm of possibility. The same thing happened to me in April after Harley's last round of GI upset/anorexia, which caused me to hold his lyso. I basically demanded a stim from my GP, I couldn't believe it, he was out of cortrysyn. He said that he had already ran ACTH on something like 3 or 4 other dogs that week.

Anyway, Nathalie, Kim is absolutely right, please do not let the vet push the test back any further than Tuesday, not only will a further delay affect getting a "true" reading on the test. My concern is that a further delay in going to maintenance, assuming that Phillip is loaded, may give his adrenals a chance to start regenerating. Some dog's adrenal can regenerate pretty fast, it just depends on the dog.

Here's big thumbs up to good result!

Debbie

Nathalie
06-22-2009, 06:41 AM
Well that’s the kicker, they have only 2 cushings dogs right now …..
Last week I had to split one dose over 2 meals because they ran out of Lysodren (once he is on a maintenance dose my plan is to buy from a local compounding pharmacy which is the least expensive that I have found at $4.30 +$10 Cdn). What bothered me at the time is that I was told that it is not a huge issue.
Not having Synacthen on hand when they know we are loading and Phillip could be ready at anytime for his stim is just not doing your job and sends a message of my boy not being important enough to have in stock what it takes to effectively treat him.
Oh well, it is what it is, I just have to be on my toes all the time and try to stay a step ahead of everything and with the help of you guy’s it does not seem such an overwhelming task anymore. So Thank You All.

Phillip is not doing too bad, actually he had a couple of ok days. The panting is terrible at times – this morning he woke up and was panting so hard and his eyes looked so big ….. very hard to watch and not being able to do anything about it. I have been taking him swimming every day – he likes to just stand or float in the water and when he comes out he rolls in the grass and seems to be a bit perkier.
He has such a hard time with the heat and today it supposed to go up to 28 C + humidity – thank god for air conditioning.
He is also shedding a lot but no real bold spots his coat looks just thin. The elbow sore is a concern – once tissue dies it can get ulcerated but with all at the vet bills at the moment I just don’t have another $150 US to buy the DogLeggs which would solve the problem.
What occurred to me just yesterday is that he has not eaten anything disgusting in a while – he used to look for poop in the backyard as soon as we used to get back from our walks but this has completely stopped (not that there is any poop around – I always pick up right away)
Well, we are off to the park now trying to beat the heat.
Nathalie

Roxee's Dad
06-22-2009, 10:16 AM
Hi Nathalie,
I am sorry that you are going thru the extra stress of your vet office not planning ahead properly. I guess you will have to be their reminder by calling them ahead of time and asking if they have the necessary items needed in stock:(. I do it with Roxee's vet just out of habit and because it's a 1 hour drive each way for us.


What occurred to me just yesterday is that he has not eaten anything disgusting in a while – he used to look for poop in the backyard as soon as we used to get back from our walks but this has completely stopped (not that there is any poop around – I always pick up right away)

I would say this is certainly a sign of loading. Roxy used to eat poop when she finished her food dish. She would go outside and look for poop, it got so bad that she would wait for her sister to poop and eat it almost as it was comming out:eek: That is what led us to take her to the vet which resulted in the vet suspecting cushings. Once her cortisol was lowered, she stopped eating anything disgusting.

Nathalie
06-23-2009, 06:24 PM
Phillip had his stim test done today – vet said that she spoke to someone (I think a pathologist) at Idexx lab and she said we need to do 2 post blood draws. Something about if number 1 is is higher then number 2 … sorry can’t remember what she said exactly, but I am not going to argue about something like that with her.

She also said that the person at Idexx said any number below 200 nml/L (7.35 ug/dl) would be fine.
I thought after we talked last time and I reffered to Dr. Feldsteins (hope I got the name right) protocol the goal would be to get him between 1-5 ug/dl (30 - 140 nmol/L, and preferably kept closer to 30). I did point out that if she where to look at Idexx Monitoring/Treatment protocol that it states to begin Maintenance at 1-5 ug/dl.
This is just not getting any easier.
She also mentioned something that he may have to go on a 2x per week maintenance dose (3000 mg per week). I told her that if the numbers are too high I wanted to keep on loading but did not really get into it without having the results back. I am hoping he is well below 5, put him on maintenance and don’t have to have another big talk again.

Oh, I also got something along the lines of ‘treating the dog in front of me, not the numbers".
Well, how will we ever know how he would feel until the numbers are down for a while unless we try.

The test results will be in tomorrow morning around 8 am and I would like to get my facts straight before I talk to her. I don’t think it would sound good if I said let me think about this and double check the info and get back to you.

If the test comes back greater then 5 I should reload and have another stim done when?
If the test comes back between between 3-5 what would you guy’s do?
If the test comes back between 1-3 we just put him on 1500 mg per week.

Nathalie

frijole
06-23-2009, 08:30 PM
Nat,

Darn it I had a long response typed and lost it. :confused: First off you are a fantastic advocate for Phillip and you are right to ask these questions. I am sorry you have to. It seems your vet isn't very experienced - my opinion

It is Dr Feldman btw. :p

I would follow recommended protocol. So whether it came back 1-3 or 3-5 I would go with a weekly dosage that is the same as you are giving daily now.

If it is higher I would continue loading. If you haven't made much progress since the original acth you might have to slightly increase the daily amount. (I had to several times :o)

My dog ceased loading the first time at 5.8. We failed to do a 30 day acth to make sure it stuck. It was almost 60 days when we did it and she was already back up to 16.8!!! So it wasn't a good load and I had to start all over again.

Doing this halfway thing she is suggesting makes me nervous. I guess I respect Dr Feldman too much to go against his recommendations. I would bring the same documentation with you for your visit and simply tell her you want to follow the established protocol of these experts. Not easy I know.,

I am soooooo praying that you are loaded so you don't have to do anything but say thanks!

Hope I answered all the questions.

Kim

Nathalie
06-23-2009, 09:32 PM
First off you are a fantastic advocate for Phillip and you are right to ask these questions. I am sorry you have to. It seems your vet isn't very experienced - my opinion

Thanks Kim. :) The kicker is that I asked her if she had lots of experience treating cushings dogs and she said yes. You are completely right – she can’t have much experience at all.

Yes, you answered all my questions – at least for now. ;);)

I am going to stick to my guns and insist on following protocol. This whole thing is really starting to wear me out when it really should not be as complicated.

Thanks again,
Nathalie

frijole
06-23-2009, 09:49 PM
Nat, another possibility is that she is afraid of the lysodren. We see lots of cases where vets go with doses so low that a dog would never load. Perhaps she has had success with the approach of double dosing 2 x a week before? Hard to say. Her heart is in the right place. Perhaps you can ask her why she is suggesting this.

We here often discuss treating the symptoms vs the numbers. That is if the dog has high numbers AFTER having loaded (above 5) and when the dog no longer is suffering the symptoms of cushings. The object of loading is to reduce the adrenals to the point they are no longer over producing cortisol and then to maintain it. Lysodren isn't new - been around a long time. I wish dosing were easier but the parameters that have been set seem to work for most. That's why I wouldn't experiment.

I truly hope you are loaded so all of this is moot moot moot. :) Glad they are turning the results around quickly. Kim

AlisonandMia
06-24-2009, 04:57 AM
She also said that the person at Idexx said any number below 200 nml/L (7.35 ug/dl) would be fine.
I thought after we talked last time and I reffered to Dr. Feldsteins (hope I got the name right) protocol the goal would be to get him between 1-5 ug/dl (30 - 140 nmol/L, and preferably kept closer to 30). I did point out that if she where to look at Idexx Monitoring/Treatment protocol that it states to begin Maintenance at 1-5 ug/dl.

I think the person at Idexx may be thinking more about a dog on Trilostane where a post of up to 200nml/L (7.35) is probably fine - ideal even. Dogs on Lysodren however really do usually do best with a post below 5 and for most (but not all) around 2. 4 - 3 seems to be ideal. 200 is a nice round number so that may influence things too, I guess.

I have noticed that confusion etc. often arises when vets rely on and consult with the people at labs (even when the people they speak to are qualified vets which some of them may be) as these people are not practicing clinicians but actually working as pathologists etc. The best person for her to consult with would be another practicing vet who has extensive clinical experience with using Lysodren to treat Cushing's - these vets invariably stick to the standard protocols at least until an individual patient shows that the protocols need to be "bent" a bit.

I too hope that he is nicely loaded and this all turns out to be a moot point!

Alison

Nathalie
06-24-2009, 08:32 AM
Just a quick note to let you guy's now that Phillip IS loaded!!!!! :D:D:D:D:D

I am ecstatic!!! :p

His numbers are:

Pre 0.6
Post 1.26 (1h)
Post: 1.47 (2)

Oh my god, I thought I would never see the day.
I have a repair guy coming in shortly and have to hustle but did not want to wait to announce the good news.


Thanks to all of you,
Nathalie

Harley PoMMom
06-24-2009, 09:43 AM
YAHOO!!!!

Good Job Nathalie!! :)

I am so happy for you and Phillip!! Harley and I are doing the happy dance for yous tonight (I am at work right now :(.)

Hugs to you both,
Lori

BestBuddy
06-24-2009, 04:23 PM
Well done Phillip.:D

How is he doing and whats the plan now?

Jenny

acushdogsmom
06-24-2009, 06:18 PM
Congratulations on a successful loading!

Now on to phase two, where you find the right maintenance dose for Phillip. Some dogs do better with their cortisol as low as Phillip's is now, while others seem to need to have it a bit higher than that.

I think the plan should probably be to start maintenance dosing (at 1500 mg per week) about a week after the last loading dose was given, and then re-stim in 30 days, to see where the levels are after one month of 1500 mg per week.

If they are still nicely within the 1-5 target range (less than 110 nmol/L is what my Specialist always aimed for with my dog) at the 30-day mark and if Phillip is eating okay and feeling pretty okay, then stick with that dose and retest in another 90 days afterwards, to see where the levels are by then.

If, however, at the 30-day mark of maintenance dosing, the stim test tells you that the numbers are starting to climb or are getting too low or if Phillip isn't feeling the greatest etc, you can make any necessary dose adjustments at that time.

P.S. Please ask your Vet to make sure they never run out of Synacthen! Although it's less likely that Phillip's numbers will be too low during maintenance, you need to know that you can get a stim done at any time, if Phillip ever shows any signs of too-low cortisol.

gpgscott
06-24-2009, 06:25 PM
Tremendous good news.

Ditto's on Cushy's remarks.

Please continue to let us know.

Scott

Nathalie
06-24-2009, 07:29 PM
Thanks Guy’s. :)

Jenny - He is actually not doing too bad right now – the heat is a real problem for him but since I am still on vacation I take them to the park at 6 am and still, his first stop is for a ‘float’ in the pond. Going in the water really helps him a lot – when he comes out he rolls in the grass and kicks his legs into the air.
He is not eating quite as fast anymore and this morning he actually paused, looked around and then went back to eating – I can not remember when he ever did this. He is also a bit more interrested in going after squirrels and rabbits – this morning he was way ahead of me, following a scent with my other hound Matthew – at one point I actually thought they where going to bolt and ditch me to go after a rabbit.
As Cushy said he is now on maintenance and the next step will be to take another stim in 1 month and hopefully the numbers don’t creep up on us.

I am very hopeful that he will start feeling much better soon.

Oh, just as I am writing this post it occurred to me that I have not heard him wheezing when sleeping on his stomach in a while and when I look at him he does not seem as pot bellied anymore.

I sure will ask the vet to make sure that they have Synacthen on the shelf – thanks Cushy for bringing this up – good point.

I do have a couple of question so ….. just double checking ;)

I am planning on splitting up the 1500 mg over several meals. What would be a good way of dividing 1500 mg over 7 days? Would it make sense to give him 250 mg for 6 days with a one day break?

Also, he started licking/chewing his front legs and chewing his pads occasionally as if he is itchy and also scratching his muzzle and ears occasionally. He does not have any sensitivities other then to some grasses that start sprouting in spring. Is this a cushings or lysodren ‘thing’ or could it be that the cortisol at this point is a bit to low for him?

Thanks,
Nathalie

StarDeb55
06-24-2009, 08:00 PM
Also, he started licking/chewing his front legs and chewing his pads occasionally as if he is itchy and also scratching his muzzle and ears occasionally. He does not have any sensitivities other then to some grasses that start sprouting in spring. Is this a cushings or lysodren ‘thing’ or could it be that the cortisol at this point is a bit to low for him?

Probably not. The more likely explanation is that Phillip may have some allergy issues that were being treated by the high cortisol levels. Now, that the cortisol is in a more healthy range, some of these issues may start "unmasking" themselves. A lot of members whose pups have what appeared to be very mild arthritis have found that with the lower cortisol levels, the arthritis will become a bigger problem. If this is, indeed an allergy issue, you need to remember that steroids for allergies are a big no, no. My 1st boy, also, had severe allergies along with his Cushing's, so it was a challenge to treat both of them, but it can be done.

debbie

frijole
06-24-2009, 08:11 PM
just a quick note to let you guy's now that phillip is loaded!!!!! :d:d:d:d:d

i am ecstatic!!! :p

his numbers are:

Pre 0.6
post 1.26 (1h)
post: 1.47 (2)

oh my god, i thought i would never see the day.
I have a repair guy coming in shortly and have to hustle but did not want to wait to announce the good news.






thanks to all of you,
nathalie

happy dance happy dance happy dance

frijole
06-24-2009, 08:16 PM
Nat, re the dosing amounts... someone wrote a wonderful answer to that once which I can only summarize. If you break the doses up too much the effect is not the same. I believe most split it up 50/50 so in your case 750 mg on 2 days. We'll see what others have to say.

I am so relieved for you. I was reliving my "load" and I remember the stress is alot and it is hard to have to deal with "how do I say this or that to the vet" on top of it. So good for you and congrats to Phillip! Dog treats are on me. :D Kim

gpgscott
06-24-2009, 08:21 PM
Hi Nathalie,

I am going to leave the dosing advice to those with personal experience.

I do know that dogs respond favorably to benedryl and I would ask about this to help with these signs of allergies.

Scott

StarDeb55
06-24-2009, 08:22 PM
I agree with Kim, most standard maintenance protocols do seem to state twice weekly. Experienced vets seem to have their own preferences though as my vet feels he has better luck with 3 times a week dosing. I'm not sure, but I think Feldman may advocate splitting the maintenance dose into several smaller doses over a week's time. I'll see if I can find the reference & post back.

Debbie

PS- Here's to maintenance dosing info I promised. The link is from the important information section of the forum. Anyway, if you will look in the maintenance section of the discussion of lysodren therapy, it's about the 5th paragraph down that states that weekly maintenance should be split into as many doses as possible.

http://www.k9cushings.com/forum/showthread.php?t=223

StarDeb55
06-24-2009, 08:26 PM
Scott has a good point about trying out an over the counter antihistamine. My other boy, Chewbacca, is being worked up by a dermatology vet, & will be going for skin testing in about 2 weeks. One of the first things he had me try was OTC antihistamines, one of which was Benadryl. Chewy weighs 20 lbs., & believe it or not, he could take up to a maximum of 3 adult Benadryl tabs daily. I was given a list of antihistamines to try. Please talk to your vet about possibly trying this with Phillip.

Debbie

BestBuddy
06-24-2009, 10:30 PM
Hi Nathalie,
I did a big of research on allergy treatments for my rescue Luke. But keep in mind he is an otherwise healthy dog. Remember to check with your vet with over the counter human drugs.

I found this like (Australian) a great help.

http://www.ingleburnvet.com.au/antihistamines.htm

Jenny

lulusmom
06-24-2009, 10:40 PM
Hi Nathalie,

Dr. Feldman does, indeed, instruct his students at UC Davis to never, ever prescribe a once weekly maintenance but rather split it up over three to four days. In Phillip's case, I personally would do 500mg on Mon, Wed & Fri. I have two cushpups and both are on three times weekly dosing and it has worked out beautifully.

Glynda

acushdogsmom
06-24-2009, 11:20 PM
Hi Nathalie,

Dr. Feldman does, indeed, instruct his students at UC Davis to never, ever prescribe a once weekly maintenance but rather split it up over three to four days. In Phillip's case, I personally would do 500mg on Mon, Wed & Fri. I have two cushpups and both are on three times weekly dosing and it has worked out beautifully.

GlyndaMy boy received his weekly Lysodren dose split into two or three doses per week (depending on the total weekly dose he was getting at the time). So I think 500 mg three times a week for a weekly total of 1500 mg sounds like the way to do it for Phillip. :)

And btw, if you ever have to move the dosing days around for whatever reason, it doesn't make a difference. (We usually dosed on Mon, Wed and Fri but sometimes changed it to Mon, Wed and Sat or Tues, Thurs and Sun etc)

Nathalie
06-25-2009, 06:38 AM
Thanks for the feedback.
Regarding the licking/chewing I am just going to keep an eye on it for now and see what happens.

Dosing 3 times per week sounds like a good plan.


I am so relieved for you. I was reliving my "load" and I remember the stress is alot and it is hard to have to deal with "how do I say this or that to the vet" on top of it.

Kim, you are so right about this – there is the dog you are worried about, making sure that test are done the right way and interpreted and trying to stay ahead of different scenarios that may arise and have appropriate responses/resources ready for the vet, plus the costs of all of this. It can get quite exhausting.

I am just hoping that he will do well on the maintenance dose and that we are not unmasking anything unpleasant.

Thanks,
Nathalie

Dollydog
06-25-2009, 07:57 AM
Congratulations Nathalie....I'm so happy for you two. Wishing you all the best with the maintenance now,
Jo-Ann & Lady :)

frijole
06-25-2009, 08:09 AM
Nat, Glynda is right regarding Feldman's philosophy - I had forgotten. You need to know that she is a guru of Feldman and is known to spend countless hours reading his presentations and probably wakes up in the middle of the night to read more. ;) So I trust she is quoting him accurately.

I agree - KISS theory. 1500 mgs is 3 pills. I would go 3 days and save the money on buying a pill cutter. :D

I too would wait a bit on the itching thing. If it continues you know it is lysodren related (or cushings). Get your feet wet with the weekly dosing deal and sit back for a while and smell the roses.

Congrats on a great load. I sure am glad you stopped the lysodren when you did. Alison is the one who recalled the Beagle appetite so kudos to her here in addition to your eagle eyes.

So go have some wine and celebrate!
Kim

Roxee's Dad
06-25-2009, 10:13 AM
Hi Nathalie,
Just wanted to add my congrats to you and Phillip. Your doing a great job :), keep up the good work and Phillip will be a happy boy:D:D

Nathalie
06-25-2009, 05:26 PM
I sure am glad you stopped the lysodren when you did. Alison is the one who recalled the Beagle appetite so kudos to her here in addition to your eagle eyes.
Kim

Oh yes, Alison’s post gave me the final push to stop the Lysodren. :)If I would have continued loading until seeing a bigger difference in how he was eating his dinner we would have been in serious trouble. I was just thinking that a dog that has been cushioned for many month and has always loved any type of food, the fast, ravenous eating can perhaps also become somewhat of a habit. So even the cortisol is down it may take a few days for the somewhat ingrained behavior to subside, making it quite difficult to know when to stop loading.
Not sure if this is indeed so but to me it would make sense.

Thanks again for all the well wishes. :)
Getting us where we are today was quite the team effort.
Nathalie

Nathalie
06-29-2009, 12:50 PM
Thought I give you guy’s a quick update – today is my last day of vacation and I sure do not want to go back to work. :(:(:( It was so nice to be able to take them for long walks very early in the morning having the park pretty much to ourselves.

There has been quite an increase in his activity level and he is way more alert. Phillip had a great walk this morning, going swimming, wondering off the path doing his own thing (he has not done this in many months) and no problem in keeping up with us anymore – he is trotting more then he is walking and after being at the park for 1.5h he still had enough energy to do a bit of a puppy run trying to chase his sister. Now that is a HUGE improvement. Mental alertness … big improvement as well. He was truly enjoying being out and about and not just going through the motion of keeping up and being preoccupied to look for something to eat. :):):)
For some strange reason water intake has gone up, but it has been pretty hot and humid for the past week so it might be just due to the warm temperature.

The sore on his elbow (http://www.k9cushings.com/forum/album.php?albumid=59&pictureid=559)is getting worse and now the left side is turning pink and a bit raised as well. I broke down and ordered the DogLeggs (http://www.dogleggs.com/files/adjustable.cfm) as there is no way I can keep both legs bandaged properly everyday.

He has had these 2 round, bold and slightly raised spots on his right hind leg for quite some time and I never thought much about it since it does not seem to bother him but just thought it to be strange since he never licked the area.
Since last week these spots turned pink (used to be skin color)and look somewhat inflamed and are now bigger – probably the size of a pea. The strange thing is that he has the same identical 2 ‘spots’ on the left leg in the same location.
When I lightly squish them between my fingers it feels like they are filled with something semi-sold. Are these calcinosis cutis? I have looked at quite a few pictures online but I am just not certain that that is what it is. I have put a picture of the ‘lumps’ (http://www.k9cushings.com/forum/album.php?albumid=59&pictureid=560)in the photo album.
If these are calcified lumps in the skin, why would these start to grow and start looking somewhat inflamed after loading and sit dormant while the cortisol was still high?

Anybody have any thoughts/experience with this?

Thanks,
Nathalie

gpgscott
06-29-2009, 01:15 PM
Hi Nathalie,

I think what you are feeling is calloused skin. Moria has similar on her elbows. On the feet they sure look like chronic abrasions to me. Is it possible his feet are striking or rubbing against each other has he walks.

Glad his energy level is better.

Scott

frijole
06-29-2009, 03:46 PM
I live in Nebraska and so I asked some people who know about these things. :p This product is used for livestock and horses for scratches and the same type problems. You put this ointment on and then wrap it a couple of times with a gauze tape (healthcare product). I would think this would be alot easier for poor Phillip and less expensive. Sorry if I am too late but I just got to the gal I needed to... Kim

http://www.qcsupply.com/qcsupply/browse/productDetailWithPicker.jsp?productId=540963&categoryId=&fromPage=search

AlisonandMia
06-29-2009, 05:41 PM
If these are calcified lumps in the skin, why would these start to grow and start looking somewhat inflamed after loading and sit dormant while the cortisol was still high?


This is actually pretty much par for the course and I had suspected that this might be what was going to happen with Phillip's "sores".:( The reason it all seems to be flaring up so badly now is that the high cortisol levels were suppressing his immune system and particularly really damping down the down the inflammatory response. Now that the excess cortisol has been removed from the picture his body can set about repairing itself properly - and this means that outwardly at least some things will seem to get worse before they get better.

If there are calcium deposits (calcitonis cutis) anywhere then they will be beginning to make their presence felt as his body sets about ejecting them as it would any irritating foreign body. I guess it is also possible that the things on his feet are the result of his having picked up something like some splintes which have sat there while the cortisol was high and now are being 'evicted' by a healthy inflammatory response. If he does have calcitonis cutis then it will be very itchy until it resolves - which it eventually will.

We have at least one member here (Angela, 'Sabre's Mum' http://www.k9cushings.com/forum/member.php?u=45) who's dog had really extensive calcinosis cutis that was pretty ghastly for about four to six weeks (I think it was) after loading. Most Cushing's dogs don't seem to get it, but when they do it can be pretty distressing especially if it is extensive. I think if Phillip had it extensively (over his back, ears, rump etc.) you would be aware of it now. If it is calcinosis cutis then hopefully it is confined to a few small lesions.

Any small, grumbling skin infection could also appear to get worse as his immune system mounts a good attack on the bacteria (or fungus). The same thing happens if you put a strong steroid cream on infected skin - it will appear to get "better" (because the immune response that is causing redness etc is damped down) but
when you stop applying the cream the infection seems to really erupt and comes back worse than ever. (My daughter sometimes gets eczema that has as component a bacterial infection (some bizarre form of stap is the usual culprit) hand we have learned to always use an antibacterial cream along with a steroid for this reason and we are pretty light-on with the steroid too.) You'll just need to treat these nasties as they come up but I really think they are going to get better eventually as his body begins to function more normally.

Speaking of things getting worse before they get better, he is probably about to start blowing his coat - if he isn't already - and he's probably going to have some pretty spectacular dandruff with it too. This is something just about every Cushing's dog goes through following successful treatment. The new coat he grows could well be a bit 'different' - probably fluffier and thicker and maybe of a slightly different color too.

It is great to hear that Phillip is back to enjoying life again - it's like a miracle isn't it, as they seem to just get younger before your eyes!:):):) It sounds like he is making a particularly rapid recovery just like my dog did. When are you starting maintenance?

Alison

Nathalie
06-29-2009, 06:07 PM
Scott, the picture of his elbow does not really show how bad it is. It started of as a callused area but has grown to a thick, soft area that keeps on growing. A couple months ago the skin broke and it was oozing fluid and the licking started which made it worse. That is when I started wrapping his elbow as best as I could which helped to a certain extend. Tissue has started to die and since the other elbow is starting to ‘act up’ now as well I can’t cope with trying to get both legs wrapped at all times. I think/hope the elbow protection will work nicely – they are easy to put on and Phillip is getting stressed by me trying to keep our current foam/vet-wrap system in place.

“On the feet they sure look like chronic abrasions to me. Is it possible his feet are striking or rubbing against each other has he walks.”

Scott, you know, you might be on to something. :) He has always had a ‘strange’ gate making this little circle movement with his hind legs. He is more active now but still quite weak in the hind end which could exasperate these ‘circular’ movements. This would explain why I am seeing these ‘spots’ now on both legs exactly opposite each other and the area is getting pink now.
I am going to have to watch him walk at the park tomorrow and let you know.

Kim, thanks for checking about the balm – I believe here we call this Bag Balm – unfortunately we have tried this along with a cream that is used for people with bad burns – it helps a bit but it won’t shrink the overgrown tissue back which is here to stay for live. In general I love this stuff – works nicely on human feet as well.:)

I think once he gets used to wearing the DogLeggs at home he won’t stress about it – it will just be part of his gear like wearing a harness etc.
Would have loved to save the money but I am tired of wrapping and cannot have it start ulcerating because then we are in BIG trouble.
Thanks,


Nathalie

Nathalie
06-29-2009, 07:18 PM
Hi Alison,

Ok, this makes sense. As long this is a normal response to the lower cortisol and part of the healing process I won’t get too worried about it. I went through something similar with my Beagle Matthew – vets called it allergies and wanted to put him on steroids indefinably because as soon as he got weaned off the ear infection and open sores/skin infection from scratching came back worse then before.
I took him off the steroids, no more antibiotics, shots, pesticides along with a fresh diet (that goes for all my dogs), and yes it got worse before it got better, but over time his immune system got back into balance and he has had no more ear infection for the past 6 mon and very little itching. I am not suggesting that this would work for every dog but it worked for him and at the time when this all started he was only around 1 year old.

He has been blowing his coat forever it seems – I am surprised he is not naked by now. It is a pretty thin/unkempt looking affair he is sporting on his torso. :D
A new coat would be great.:):)
No increase in dandruff so far, but thanks for the heads up. I seem to be dealing with things better if I know

The changes, particular over the past 3 days have been quite amazing – now I am starting to see my Phillip again and he is coming out of his ‘bubble’ again.
I gave him his first maintenance dose tonight.

I don’t know if I ever mentioned this before, but Phillip was under the care of a homeopath when I first suspected cushings but nothing was confirmed. I have had a hell of a time deciding to treat with Lysodren (she basically told me I would be killing my dog etc.). I emailed Dr. Jean Dodds and asked her what she would do and she said treat conventionally.
I am so glad I did.
Thank you very much for all of your ongoing support.
Nathalie

BTW: has anybody ever heard or seen the reversal of premature graying in the face of a cushings dog? I have seen it once in one of my foster dogs – all white in the face and about 6 months later some of the brown colored fur returned. I just looked at Phillip and the ‘bridge’ of his nose seems to be less grey.

Nathalie
07-04-2009, 07:14 PM
I ‘think’ I figured out what the sores on his hind legs are … Scott, I have watched him walking and his hind legs don’t come close at all when walking – I thought you had it nailed with your suggestion of ‘abrasions’.
As I was in the kitchen making dog food Phillip was laying by the door and it suddenly came to me these are pressure sores :(:(:( as well. Most of the time he layes down ‘froggy-style’ and the sores are presisly where his hind legs rest on. That is why I am seeing these on both legs. His DogLeggs arrived yesterday – just in time, the sore on his right elbow is very inflamed (thick and crimson red) and he broke skin the other day and it started to bleed.:eek:
He is still getting used to wearing them but they provide great cushioning in the elbow area and I am hoping it will help to heal this sore.
He is blowing his coat like crazy – tried brushing him the other day but he hates it so I let him be. He has never been one who enjoys brushing but now it stresses him out. I was thinking maybe it does feel uncomfortable to him because he does not have much body fat on his back and side of his body.
Its been 2 weeks after loading and 1 week on maintenance – maybe he would be better on a bit higher cortisol level to help with the inflammations … just thinking out loud.
I am just so worried about these sores getting ulcerated. :(:(:(
Nathalie

BestBuddy
07-04-2009, 07:49 PM
Hi Nathalie,
I just wanted to comment on the hair color change. I have no idea if it is documented anywhere but I have always believed that illness and stress can change the hair color...usually gray. Buddy's color change when his cortisol came back into normal range was quite dramatic...he went from white to orange. It was quite a shock but after several months and a clip the color went back to normal, still not as white but back to the color he had been years ago.
Jenny

Nathalie
07-04-2009, 08:35 PM
Hi Jenny,
I believe that is so true, about 10 years ago I went through a few dramatic events within a short amount of time – I was hospitalized and had a devastating house fire – my hair went quite gray in the following months.
It is also documented that cushings causes ‘fading’ in color and premature graying. Phillip had that gray look in his face since he was 8 years old – people used to call him ‘old’ which used to really bother me. But looking back, I think he has been cushinoid for more then 2 years.


Buddy's color change when his cortisol came back into normal range was quite dramatic...he went from white to orange.
Jenny

That must have been quite the shock – if Buddy is a poodle he might have been able to pass as ‘apricot’ – just kidding. ;):)
Nathalie

Harley PoMMom
07-12-2009, 06:38 PM
Hi Nathalie,

Was just wonder how Phillip was doing with his maintenance and DogLeggs. Still blowing his coat too?

Lori

Nathalie
07-12-2009, 07:51 PM
Hi Lori,
Thanks for asking. :):)

I think he is doing ok – we had a few great days where he had so much more energy and drive to hunt and enjoy being in the water.
Today he was not quite as enthusiastic on our walk but I don’t think it is anything to be concerned about yet.

I started brushing him last week to get most of the loose hair out – I have not properly brushed him in months because it did seem to be uncomfortable and stressful for him – it took me 2 days to get most of the hair out (very oily and dandruffy) but he looks quite spiffy now I must say. :p
He still sheds but it does not look like he is going to be naked anytime soon.

Appetite is still the way it should be, water is still a bit up but nothing over the top and he seems to be loosing the pot bellied appearance and sagging back (looks overall trimmer).

Now the pressure sores are still a problem :(:(:( and I am just keeping an eye on the ones he developed on the inside of his hind legs. Curiously they are worse on the right hind leg – the bad elbow sore is on the right side as well. He must be putting more pressure on that side and also sleep more on the right side as well.

The DogLeggs are worth every penny and then some. I should have ordered them months ago. He has been wearing them since last Friday and the swelling has gone down about 80%. Considering he just layes around unless we are out walking that is a huge improvement.
Yes, he did not like them and it took some days for him to get used to it but now he excepts them as part of what we do.
The problem is that because there was so much swelling at the end and inflammation the skin has become really stretched and thin and it does not take much for it to break and bleed.
Healing is slow – his immune system must be quite compromised at this point.
We had a couple of really hot days here and I felt sorry for him not being able to go in the water to cool off and be on a leash (my dogs are not really used to leash walking) so I took the DogLeggs off while at the park and sure enough the skin broke and it started bleeding again.
I am also using (sparingly) Flamazine ointment (used for people with burns or ulcerated bed sores) to keep it from getting infected.
I am a bit angry with myself for not ordering them sooner because then we would not be in the mess we are in right now.

I have also started him on Milk Thistel and we will be going in for another stim and thyroid test in 2 weeks.

Nathalie

frijole
07-12-2009, 07:57 PM
Nathalie, Thanks for the update. It sounds like you have things under control as usual. :p It is normal that cushings dogs take longer to heal. Good job and it is great to hear from you. Kim

Harley PoMMom
07-12-2009, 08:22 PM
Nathalie,

So happy things are going so well, and please don't be "angry" with yourself, we all have been there, we live and learn.:(:mad::):D Now we know from YOU and Phillip's experience that the DogLeggs work and that is exciting news our cushpups.

You are doing are a wonderful job and please keep us updated.

Hugs from your PA. friends.
Lori and Harley

Nathalie
07-13-2009, 07:48 PM
Thanks guys! :)


It sounds like you have things under control as usual. :p Kim

That's a good one Kim - I like your sense of humor. :p

Until the next crisis. :p
Nathalie

Nathalie
07-22-2009, 06:46 PM
Phillip is going in for a stim/thyroid test on Saturday which made me go through the resource section to look at the monitoring protocol using ACTH testing.

I already know Phillip’s cortisol has gone up – his appetite has increased, and I found him counter surfing and nibbling on a piece of wood and just overall being more food motivated. None of it is over the top but I certainly can see the difference since the beginning of this week which is week 3 for being on a maintenance dose and 4 weeks since loading.

From Guidelines for monitoring Lysodren therapy with ACTH stimulation testing (Auburn) (http://www.k9cushings.com/forum/showthread.php?t=207)
3. Cortisols well above 110 nmol/L; re-initiate loading lysodren at 50 mg/kg on a daily basis for 5 days. Retest with ACTH after 5 days to see if cortisols have dropped, and continue daily lysodren until they do. Once cortisols have dropped into “ideal” range, restart maintenance (weekly) therapy, but increase dose 50% above that used previously.

4. Cortisols only slightly above 30-110 nmol/L; increase weekly lysodren dose by 25%, retest with ACTH in 4-6 weeks.

I am wondering, what would be a cortisol level well above 110 nmol/L as well as only slightly 30-110 nmol/L?

I hope he is still within the 30-110 nmol/L range as he appears to be doing emotionally better on what I think is a higher cortisol level then the first couple of weeks after loading.
His elbow sore has finally healed nicely and he no longer has to wear his DogLeggs at the park.

Almost forgot - while we are already taking blood would it be useful to have his liver enzymes chececked? Back in Februaryar his ALT was only slightly elevated but ALK was > 2400 so about 18x higher then it should have been.

Thanks,
Nathalie

lulusmom
07-23-2009, 10:49 AM
Nathalia,

Most of us are used to seeing our stim results in ug/dl so we convert the nmol to ug/dl by dividing the nmol by 27.59. The desired post stim range in ug/dl is between 1 and 5 which equates to 27.6nmol/L and 181nmol/L. I think the folks at Auburn would like to see a cushdog somewhere in the middle of the desired range, hence the lower upper range of 130 of 110 nmol/L. If Phillips next post stim is between greater than 181nmol/L but less than 276 nmol/L, most vets would increase his maintenance dose. If higher than that, then a reload will probably be necessary. I used to tell members that once the post stim gets as high as 181 nmol/L, that increasing the maintenance dose will probably be ineffective. However, that was not the case with my little Lulu. She is less than five pounds and her post stim was 11.4 ug/dl (314.5 nmol/L). Because of her wee size, her IM did not want to reload so instead or reloading, he increased her maintanance by 1/3. I am happy to report that it worked and her last post stim on Sunday was 4.2 ug/dl (152 nmol/L). Just keep in mind that that has not been the norm with most cushdogs here.

Glynda

P.S. I would wait to do another blood chem to check the liver enzymes until you know that Phillip's post stim is where it needs to be and the infection on his legs have totally healed. By the way, those sores are called compression sores and they are common in cushdogs, especially those that are extremely listless and lay around putting constant pressure on those areas that are in contact with the floor. They are slow to heal but recovery does speed up once you get the cortisol in check. It looks like you are seeing a lot of healing now so that is a great sign. The milk thistle boosts the glutathione levels needed to help the liver recover, so it will help greatly as will the lowered cortisol.

Nathalie
07-23-2009, 02:29 PM
Hi Glynda,



Most of us are used to seeing our stim results in ug/dl so we convert the nmol to ug/dl by dividing the nmol by 27.59...

Sorry, I completely forgot to convert first instead of just copying and pasting. :rolleyes:
Thanks for the clarification – I feel better when I have my ducks in a row BEFORE decisions have to be made.



I used to tell members that once the post stim gets as high as 181 nmol/L, that increasing the maintenance dose will probably be ineffective. However, that was not the case with my little Lulu. She is less than five pounds and her post stim was 11.4 ug/dl (314.5 nmol/L). Because of her wee size, her IM did not want to reload so instead or reloading, he increased her maintanance by 1/3. I am happy to report that it worked and her last post stim on Sunday was 4.2 ug/dl (152 nmol/L). Just keep in mind that that has not been the norm with most cushdogs here.

I am glad that upping the dose worked and your dogs test result came back at such a nice number. Less than 5 lbs ... that sure is tiny. I have a Chihuahua girl and she weighs in at 11.5 lbs – not overweight, just very muscular and on the bigger side. Now compared to Phillip she looks tiny, but a little guy like yours ... it’s hard to imagine. :)



I would wait to do another blood chem to check the liver enzymes until you know that Phillip's post stim is where it needs to be and the infection on his legs have totally healed. By the way, those sores are called compression sores ....
That makes complete sense – so I will wait. Never heard the term compression sores – I just usually call them pressure sores when people ask me and compare them to bed sores if anybody is really curious why Phillip is wearing cushioning over his elbows.
Yes, it took 3 weeks to heal this small spot where the skin broke but it finally healed and some proper skin is now covering the area – still pink and fragile but at least skin that does not break when he licks it a couple of times.

Thanks again, :)
Nathalie

Harley PoMMom
07-27-2009, 10:25 AM
Phillip is going in for a stim/thyroid test on Saturday...Did you get Phillip's results back?
Thanks,
Nathalie




Nathalia,

I am happy to report that it worked and her last post stim on Sunday was 4.2 ug/dl (152 nmol/L).
Glynda

Glynda, I am so happy for you and Lulu. :D:):D:)

Hugs to both of you.
Lori

Nathalie
07-27-2009, 06:15 PM
Hi Lori, thanks for asking. :)

The test results are back ....


Stim test:

Pre: 2.86 (82)
1h: 6.52 (180)
2h: 7.5 (201)

The vet suggested to increase his Lysodren from 1500 mg per week to 2500 mg. I think this might be too much.
25% of 1500mg = 375

I think, based on Glynda’s previous post, if I increase to 2000 mg it hopefully will keep the cortisol low enough. Keeping also in mind that Phillip is feeling emotionally better in the upper range and is also less itchy.

What do you guy’s think?
Thoughts, feedback, suggestions, Donations (just kidding obviously about the donation part, but all these test are killing me and no end in sight yet) ... ;)

Thyroid update:
1 month ago we did an unplanned Thyroid test while doing a stim test to safe costs (per vets suggestion). Back then I was really preoccupied absorbing all the Cushings information/getting him on a proper loading protocol so I did not think twice when we drew blood at 3.30 pm that day.
Back then his T4 came back at 19 nmol/L (1.4 ug/dL ) (should be between 28.3 -57.9 nmol/L or 2.20 – 4.50 mg/dL which is the optimum geriatric level ). So I upped the dose from 0.4 to 0.6. On Saturday his T4 was 81 nmol (6.29 ug/dL) – way too high. I knew I had to decrease the dose but I kept thinking about these numbers and then it suddenly struck me ..... Shelf-live is about 9h, the T4 test was done 9.5h post pilling – yikes :eek:. So he is back on 0.4 mg of Soloxine 2x per day – poor guy should not have to go through these up and downs needlessly.:(:(:( The thyroid test 2 months ago was our first test since he started Soloxine – back then I did not know thyroid levels peak 4-6h post pill so this time I made sure we used a blood sample taken within the 4-6 h window but I don’t think these type of things should not be my sole responsibility. Very frustrating.

I previously had emailed Dr. Jean Doods with some questions and thought I post my questions and Jeans responses here as well for anybody who might be interested.

“Optimal therapeutic response levels should be in the upper 1/3 to 25% above the upper limits of the resting optimal ranges at 4-6 hours post-BID thyroid medication.”
Explanation:
Geriatric Therapeutic Optimal Levels:
T4 2.20 – 4.50 ug/dL
FT4 0.70 - 2.00 ug/dL
T3 40 – 70 ug/dL
FT3 1.6 - 3.5 ug/mL

Question: How often should I have his thyroid function tested and what tests should be done?
Answer: Every 6-12 months; test T4 and freeT4.
Question: I have read that we should test not only for T4 but also Free T4 – is this correct and what does the Free T4 value in conjunction with the T4 value supposed to tell me?
Answer: Definitely, because freeT4 is the biologically active tiny fraction [0.1 %] of total T4 .
Question: How to convert T4 value from nmol/L to ug/dL
Answer: you must divide the nmol/L by 12.87 to convert it to ug/dL

The pressure sores on his hindlegs are now becoming a problem/starting to grow and look inflamed – I already emailed the people at DogLeggs and will be speaking with them to make him some custom booties.

I am feeling a bit overwhelmed right now with all the expenses and having to make sure that he gets the proper treatment that he deserves.

Sorry for the long winded post, again.
Nathalie

Harley PoMMom
07-28-2009, 06:21 PM
Hi Nathalie,

Remember we are always here for you...we do not mind reading...the typing, sometimes I get frustrated with...I still type with two fingers. :eek::mad::)

The only thing I can say is some people do treat their cushpups by how their pup is feeling and acting and not entirely by the number, I don't have any experience in this type of treatment so I can not give you any concrete advice. So I'm sure someone will be along to give you guidance in that regards.

Thank you so much for sharing your email with Dr. Jean Doods with us, I hope you didn't mind that I copied it, I found it very informative. I am in awe of you...Nathalie, everything you have learned since you've been here...cushings, Lysodren and everything that goes with that :eek:, thyroid, and the list goes on. You have had ALOT to deal with emotionally and financially...know we are here and understand completely. Would your vet let you make payments instead of paying in full at the time of visit? Just a thought, don't know if it would help or not.

Many Hugs to you and Phillip.
Lori

Nathalie
07-28-2009, 07:43 PM
Hi Lori,
Thank you so much for your kind words! :)


Thank you so much for sharing your email with Dr. Jean Doods with us, I hope you didn't mind that I copied it, I found it very informative. I am in awe of you...Nathalie, everything you have learned since you've been here...cushings, Lysodren and everything that goes with that :eek:, thyroid, and the list goes on. You have had ALOT to deal with emotionally and financially...know we are here and understand completely. Would your vet let you make payments instead of paying in full at the time of visit? Just a thought, don't know if it would help or not.
Lori

By all means, that is why I posted Jeans responses – thought it might be of interest/use to someone else.
Yes, I did learn a lot but its just not enough to pull it all together and that is why the mistake happened with Phillip’s thyroid test. :( This is why I am so grateful I found you guy’s. I just wish I could contribute more instead of just using the group to help me help my Phillip.:o

There is just a lot going on right now such as a sick cat who is peeing all over the furniture, and water in the basement because of all the rain we been having this summer in Ontario etc. I won’t bore you with the details – I think you get the picture.

Yes, I hope someone can give me some feedback/thoughts on how much to up the Lysodren.

Thanks again,
Nathalie

AlisonandMia
07-28-2009, 08:01 PM
Hi Lori, thanks for asking. :)

The test results are back ....


Stim test:

Pre: 2.86 (82)
1h: 6.52 (180)
2h: 7.5 (201)

The vet suggested to increase his Lysodren from 1500 mg per week to 2500 mg. I think this might be too much.
25% of 1500mg = 375

I think, based on Glynda’s previous post, if I increase to 2000 mg it hopefully will keep the cortisol low enough. Keeping also in mind that Phillip is feeling emotionally better in the upper range and is also less itchy.

What do you guy’s think?
Thoughts, feedback, suggestions, Donations (just kidding obviously about the donation part, but all these test are killing me and no end in sight yet) ... ;)


You know, I think I'd go with the higher dose that the vet suggested as it will bring down the numbers faster.

My way of looking at it is that there are three possible doses of Lysodren when you are treating a dog with PDH:

1. A loading dose - that is a dose that is actively eroding the adrenal cortex and therefore bringing the stim numbers down.

2. An adequate maintenance dose - that is a dose that is neither actively eroding the adrenals or allowing them to regenerate under the influence of the ACTH being pumped out by the pit. tumor.

3. An inadequate maintenance dose - a dose that is allowing those adrenals to regenerate and thus the numbers have risen.

When you up the maintenance dose to bring the numbers down when they are a tad above the desired level, what you are really doing is slow, low dose load. If, once you've got the numbers (and symptoms) where you want them, you persist with that dose because you believe it is the right maintenance dose you will eventually get into an overload situation because that dose is actively eroding the adrenal cortex. This means that once you are back in range what you need to do is to decide on a new maintenance dose - usually somewhere between the old (inadequate) maintenance dose and the increased (slow loading) "maintenance" dose. Then you need to te$t a month after starting that new maintenance dose to check that it is holding things stable.

It is a great thing that Phillip's appetite gives you such a good indication of where his cortisol is at. Do you have a food (maybe the apples) that he is voracious with when his cortisol is out of range but more polite or even reluctant about when it is in range? With my Mia this food was broccoli - when her cortisol was too high she positively attacked it (along with anything else carbon-based) but when her cortisol was under control she'd eat but only if there was nothing else in the offing and would very often only decide that she needed to eat it when it looked like our other dog might get it instead!

While you are going through this "loading" phase as you try to bring the numbers down, be paying attention to his appetite. It may well take less than a month on that higher dose to get him loaded again.

Alison

Nathalie
07-28-2009, 09:38 PM
Hi Alison, :)

I read your response about 5 times and I think I am having a light bulb moment. My mistake was to look at the new dose as his new maintenance dose and not as a low-dose load.
Looking at it this way this changes things ….
1500 mg was an inadequate maintenance dose, 2000 mg might be an adequate maintenance dose but we first must erode the adrenal sufficiently with a low-dose load in order to maintain a lower cortisol level.

His only symptoms that previously where gone/or less are an increased appetite, trying to snack on something gross, but with not much interest, that he would not have looked at 3 weeks ago, and being more sharky when taking treats and perhaps a bit more lethargic (a couple of weeks ago he was doing the occasional puppy run). Almost forgot - it appears that he has a bit of a pot-belly again.

I think I could use apples and the way he takes a treat from me as a gage. Yikes, and I thought we had that nerve wrecking time of loading behind us.
Ok, I will up him to 2500 mg per week – I am worried, but if it needs to be done. I just don’t want him so low that he gets worried about things again.
What would be a good schedule? Should I give him 1 pill every day of the week and none on Saturday and Sunday?

Thanks,
Nathalie

AlisonandMia
07-28-2009, 09:54 PM
So you will be giving 5 pills per week. Probably best to do say, Monday, Tuesday (skip Wednesday) Thursday, Friday (Skip Saturday) Sunday and so on. That way you'd be getting a more even level in his blood than you might if you miss the two consecutive days. There's also splitting up the pills in some way so he gets some every day too (although it wouldn't be practicable to give same dose daily by splitting pills, I don't think). However, I wouldn't think there would be a lot to gain by splitting the pills - as long as he gets the 5 in the week and the skipped days are kept separate then that would be fine. I think that is what is what I'd do - just the 5 whole pills and no messing about with cutting them up.

Good luck with the "apple sign" - it sounds like you are already well on your way to being the world expert on your dog's Cushing's which is very, very useful when treating this disease.:)

Alison

Nathalie
07-29-2009, 12:56 PM
Thanks for the clarification and advise Alison.



Good luck with the "apple sign" - it sounds like you are already well on your way to being the world expert on your dog's Cushing's which is very, very useful when treating this disease.:)


I am not too sure about the ‘expert’ part :) but I am determined which also really helps. ;)
Have a great day,
Nathalie

Nathalie
08-03-2009, 08:55 PM
Phillip has been on 2500 mg of Lysodren for the past week (previously 1500 mg) and is getting more and more hungry. Tonight I found him eating poop – this is way over the top – he has not done this since week 2 when we first started Lyso. :eek:Now I am worried that his cortisol is way up and going higher and he needs a mini-load.:confused::(
What to do in a case like this?
I don’t know if this is related, but I also noticed he has more intense hind leg tremors for the past few days. Shedding is out of this world – his butt looks like I clipped his hair – he only has undercoat left.

Nathalie

frijole
08-03-2009, 09:01 PM
Nathalie all of the symptoms including the hind legs shaking are signs of uncontrolled. cushings.. that is strange with the increased dosage. Refresh my memory what the last acth test result was and when it was. Sorry.. I think I am getting feeble. ;) Kim

Nathalie
08-03-2009, 09:11 PM
HI Kim,


Nathalie all of the symptoms including the hind legs shaking are signs of uncontrolled. cushings.. that is strange with the increased dosage. Refresh my memory what the last acth test result was and when it was. Kim

It was my understanding that the tremors are due to muscle loss. So are you saying that higher cortisol levels cause tremors that are not related to muscle loss or are the tremors intensified by higher cortisol levels?


Test was done on July 25th

Stim test:

Pre: 2.86 (82)
1h: 6.52 (180)
2h: 7.5 (201)

I just don’t understand, what’s happening here. Poop eating is a sure sign he feels he is starving. Have not seen this in months. Ok – I am trying to not get myself worked up over this ...... yet.
Nathalie

frijole
08-03-2009, 10:25 PM
I went back and read thru the thread to refresh my memory of the timeline... You had a great load at 1.47 but within 30 days you were at 7.5. Vet increased the weekly amount instead of doing a miniload. My guess is that 2500 weekly isn't enough to bring the number down and thus the increased appetite.

Re the legs. My dog's legs trembled prior to treatment and after about 30 days of loading they quit trembling and knock on wood... 3 yrs later no more trembling. Yes she has muscle loss which she will never regain but the trembling is gone.

I would phone your vet and report in. My gut says you might have to do a miniload. Keep in mind that you might only have to do it for a few days to get back down to where you were..

I'm sorry. :( Hugs, Kim

Nathalie
08-04-2009, 08:31 AM
Just got off the phone with the vet - I am starting him on a mini-load today. She is a bit concerned that he might go to low but said if I think the cortisol is going up we need to do a mini-load. She is going to be on vaccation starting monday so I hope that it only will take a few days for him to get loaded.
Yikes - we need a serious break around here.
Nathalie

frijole
08-04-2009, 09:09 AM
Thanks Nathalie. I would like to know what the current acth is... Guess you just did one 7 days ago... thinking out loud here

Are you loading at 2500 mgs? I agree with your vet to watch carefully because it could come quickly. But I know you are a hawk and will do an excellent job. Good luck! Kim

Nathalie
08-04-2009, 01:13 PM
Thanks Nathalie. I would like to know what the current acth is... Guess you just did one 7 days ago... thinking out loud here

Yes - the last test was on July 27th and the post number was 7.5.


Are you loading at 2500 mgs? I agree with your vet to watch carefully because it could come quickly. But I know you are a hawk and will do an excellent job. Good luck! Kim

No, 1500 mg per day which is his original loading dose. Trust me, I am worried too. I hope I am reading him correctly, but when I saw him eating wood and poop last night and him actually coming into the bedroom for some apples the cortisol must be on the rise I think. Gee, I hope I am not wrong. What freaks me out is the cumulative effect of the Lyso for the 48h post last dose. I remember his appetite going down significally in those 48 after I was sure that he must be loaded.

Thought I compile is Lyso and test result history for easy reference.

May 30: started tx on 1500 mg of Lysodren 2x per week (Result: stopped eating anything inapprobriate around week 3. All other symptom remained)

June 11: ACTH test result:

Pre 4.2 (116)
Post (1hr) 9.6 (266)
Post (2hr) 11.8 (326)

June 13: started loading dose of 1500 mg daily (Result: appetite normal, more energy, loosing pot-bellied appearance)

June 26: ACTH test results

Pre 0.6
Post 1.26 (1h)
Post: 1.47 (2)

June 29: started maintenance dose of 1500 mg per week (Result: around week 3 his appetite started to increase and energy level dropped a bit. He is looking slightly pot-bellied again.)

July 27: ACTH test results

Pre: 2.86 (82)
1h: 6.52 (180)
2h: 7.5 (201)

July 29: started low dose load at 2500 mg per week (Result: end of week one, eating poop, snaking on wood and other things. Hair is coming out in clumps)

August 4 (today): starting mini load at 1500 mg per day

Nathalie

frijole
08-04-2009, 01:52 PM
Natahlie, Thanks for doing that.. it makes it real easy and cuts down on errors in offering advice also. What I'd be interested in from some other senior members is their thoughts on how to keep the numbers down...

It is a little unusual to have a dog load in 2 weeks (and a low number at that) and then after a month be high. That means the maintenance dose wasn't enough. So you increased it a LOT (1500 to 2500) and the symptoms are increasing instead of going away...

My concern is what weekly dosing regime will KEEP you at the desired levels... because we already know that 1500 doesn't work.

Don't worry Nat.... no two dogs are the same.. and we like challenges. You are a great mom and pupil .. all will be fine. Kim

Nathalie
08-04-2009, 03:57 PM
It is a little unusual to have a dog load in 2 weeks (and a low number at that) and then after a month be high. That means the maintenance dose wasn't enough. So you increased it a LOT (1500 to 2500) and the symptoms are increasing instead of going away...

I think that is probably due to low-dose loading of 1 month prior to starting a real loading protocol on June 13.
The symptoms started increasing around week 3 while he was on a maintenance dose of 1500 mg and by the end of week one on 2500 mg (yesterday) he was eating poop, wood and something unidentifiable, apple eating is up and he is very excited around mealtimes. Water intake might be up to, but I am not sure as it has been quite warm here for the past few days.


My concern is what weekly dosing regime will KEEP you at the desired levels... because we already know that 1500 doesn't work.

Don't worry Nat.... no two dogs are the same.. and we like challenges. You are a great mom and pupil .. all will be fine. Kim

That is what is getting me so worried right now. 1500 mg is not enough and I have a gut feeling that 2000 mg might be too low too. All these tests ......... yikes. So how would one determine a proper maintenance dose at this point? Just as a reminder, Phillip's vet does not seem to have vast hands-on experiance tx cushings so we can use all the help we can get.

Nathalie

frijole
08-04-2009, 06:32 PM
Yes Nat I too wish your vet had more experience. :p;) Bless you for taking the initiative you have.

Question regarding diet.. have you made any changes since first loading Philip? Thanks Kim

StarDeb55
08-04-2009, 06:44 PM
To expand a little on what Kim has asked about diet, does Phillip normally eat a low fat or reduced fat kibble. Have you made any dietary changes in the past month that might have reduced the amount of fat in his diet? Also, can you remind exactly how you are giving the lyso, meaning is it hidden in some type of treat or food, & what specifically?

I'm asking these dietary questions because lysodren must have an adequate amount of fat in the diet to be properly absorbed.

Debbie

Nathalie
08-04-2009, 07:05 PM
No, no changes in his diet – I have been feeding raw for the past 6+ years. Except for a few month last year where I tried grain-free, human grade kibble and he did terrible on it.
I don’t make my own mush but buy a product called Urban Wolf which is essentially veggie/fruit/calcium etc freeze-dried. and I add Sunflower and Flaxseed Oil, water and lean ground beef. They also get eggs and fish such as Mackerel and Salmon occasionally.

I have always giving him the Lyso wrapped in ½ slice of soft white bread that is covered with peanut butter right after his meals.

So no, since starting the Lyso their have been no changes aside from giving him Milk Thistal 2x per day for the past 3 – 4 weeks.

Nathalie

Wylie's Mom
08-04-2009, 07:30 PM
Hi Nathalie,

I'm struggling with trying to get the right maintenance dose, too - I feel for you. But one thing I'm wondering about is Phillip's thyroid levels... could it be that they are still too high, causing him to be Hyperthyroid (instead of Hypo) and that may be the cause of the poop eating & increased cush-like symtoms?

http://dog-care.suite101.com/article.cfm/soloxine_brand_of_levothyroxine_for_dogs

Soloxine and most other forms of levothyroxine are typically very safe medications, but overdosage with the medication can result in:

increased thirst
increased urine volume
increased appetite
hyperactivity or other personality changes
reduced tolerance to increased temperatures
Soloxine and other forms of levothyroxine need to be used with caution in dogs suffering from heart disease or hypertension.

Hypertension is common in Cushpups.

Before my pup's Cushing's dx, a (former) vet suggested treating him for Hypothyroidism (he had a boarderline low T4 level, definitely low if you go by Jean Dodds). I had my pup on Soloxine and it caused his T4 to go too high, we lowering the dose and it was still too high, she wanted to go to an even lower dose but I spoke with a more senior vet and he didn't think I should bother. I'm now positive that he had Cushing's then and that the Cushing's was the main cause of his low T4. I'm not saying this is the same in your case, but since Phillip does have Cushing's (& possibly hypertension), I think treating the Hypothyroid concurrently is very tricky... and if the meds are causing him to go hyperthyroid, that would not be good for his heart.

-Susy

AlisonandMia
08-04-2009, 07:39 PM
First off - I think you are doing the right thing doing an actual mini-load now.

Looking at what you feed I'm wondering if his diet isn't actually a little low in fat from the point of view of absorption of the Lysodren and that is why 50mg/kg hasn't been doing the job. One of the "funny" things with Lysodren is that it depends on fat/oil in the food to be absorbed properly. In fact on an ultra-low fat diet the Lysodren seems to just about go through unabsorbed. A low fat diet is however a good thing for a Cushing's dog and I don't think you need to change his diet in a big way - there is another solution.

I'm a raw/homecooked feeder as well and had a problem with stabilizing Mia and her Lysodren dose. In our case it lead to an eventual overload when her food consumption (and therefore fat consumption) went up significantly in the winter - being such a little dog her food needs always increased quite dramatically when it was cold.

That made me realize very clearly that when you are using Lysodren the dose of fat/oil in the food with which it is given matters as much as the number of mgs of Lysodren you are giving. If the fat content of the food is not consistent (or sufficient) then the effective dose you are giving is not consistent (or sufficient). So I decided that I would give her her Lysodren in a special, dedicated "Lysodren meal". As a base for that meal I used the leanest mince I could get (here that is kangaroo mince). To that I added a certain amount of fish oil and I gave her the Lysodren in a small ball of full-fat cream cheese. She had her "Lysodren meal" at least 2 hours away from any other food (usually on Tuesday and Saturday afternoons). This way I could keep the amount of Lysodren she absorbed standardized and after that we had no more problems with overloading or unloading.

Good luck with the load and keep us posted.

Alison

frijole
08-04-2009, 08:20 PM
Alison I am glad you saw this because I knew you were the one that had figured out the correlation between fat intake and lysodren... Nat, that is why I asked the question.

Nathalie keep up the good work.. I know it is frustrating. It would be so much easier if there was a simple rule in treating cushings... but there isn't. We will keep an eye out for your updates. Kim

Nathalie
08-04-2009, 10:05 PM
I'm struggling with trying to get the right maintenance dose, too - I feel for you. But one thing I'm wondering about is Phillip's thyroid levels... could it be that they are still too high, causing him to be Hyperthyroid (instead of Hypo) and that may be the cause of the poop eating & increased cush-like symtoms?

Susi, I have no idea how I could have missed your post where you listed all the stim tests you have done so far – you sure do know how stressful and frustrating this all is. I have to make sure I read through your threat.
About 6 weeks ago his T4 came back at 19 nmol/L (1.4 ug/dL ) and I increased from 0.4mg to 0.6mg. Then on July 27 his T4 was at 81 nmol (6.29 ug/dL) (should be between 28.3 -57.9 nmol/L or 2.20 – 4.50 ug/dL. So yes, he went hyperthyroid. Since then he is back on 0.4 mg. The low T4 6 weeks ago was due to the test being done 9.5h post pill.
I guess it might be a good idea to do a thyroid test with his next stim.




That made me realize very clearly that when you are using Lysodren the dose of fat/oil in the food with which it is given matters as much as the number of mgs of Lysodren you are giving. If the fat content of the food is not consistent (or sufficient) then the effective dose you are giving is not consistent (or sufficient). So I decided that I would give her her Lysodren in a special, dedicated "Lysodren meal". As a base for that meal I used the leanest mince I could get (here that is kangaroo mince). To that I added a certain amount of fish oil and I gave her the Lysodren in a small ball of full-fat cream cheese. She had her "Lysodren meal" at least 2 hours away from any other food (usually on Tuesday and Saturday afternoons). This way I could keep the amount of Lysodren she absorbed standardized and after that we had no more problems with overloading or unloading. Alison

Alison, I am a bit confused now. So I don’t need to up the fat content of his regular meals but need to add more fat to the ‘Lysodren sandwich’ I am currently giving him? If yes, and the peanut butter is not enough how would I know what else and how much? Would it be enough if I add 1 tablespoon of full-fat cream cheese and maybe a teaspoon of Sunflower or Flax seed oil?
And, would I start doing this now while doing the mini-load or once back on a maintenance load? I thought the Lyso needed to be given right after a real meal to avoid stomach problems?

Thank you for all your ongoing support,
Nathalie

frijole
08-04-2009, 10:27 PM
I am going to let Alison explain about the fat content and I will read an learn from her as well.. but regarding when to give the lysodren ... you are loading so YES do continue to give food first and lysodren last... because you can't take the pill back once you give it. Just like before, monitor intake and if there is any deviation from norm don't give the pill. So don't put cream cheese on it til the food is gone and you know you are going to give it. :D

Nat, my dog took lysodren for 45+ days before loading so I understand the stress. Like I said, they are all different. Hang in there!

Kim

AlisonandMia
08-04-2009, 10:33 PM
I think during loading I'd keep things basically as they are meal wise, because observing normal behavior is so important during the loading phase. You could try upping the fat/oil intake that goes along with the Lysodren in the ways you suggested.

The "Lysodren meal" I gave Mia was about 1/2 to 2/3 or her usual meal (depending on the time of year and the amount of exercise she'd had etc). On the days she had the Lysodren meal she'd have a slightly smaller dinner than usual. It was something I did to make sure that any variation in either the ingredients or quantity of her normal diet didn't impact on the Lysodren.

Another thing that is sometimes recommended when it seems that there is an absorption problem with Lysodren is that the Lysodren be ground up and suspended in a tsp or so of warm corn oil (don't think it has to be corn oil - any edible oil will do) and this be mixed through a small amount of wet food which is given just after the normal meal. The grinding up the the Lysodren is meant to increase its absorbability and makes sure that it comes in contact with the oil thorough and predictable way. Despite the fact I did actually grind up Mia's (for slightly different reasons though) I always think if you can avoid messing about with the stuff yourself (ie grinding) it is a good thing - and more convenient. If you do decide to grind it up, do be careful re contamination and use utensils you can be thoroughly washed. When I had to cut up Mia's Lysodren (and she needed 2/5 of a tablet a week so it wasn't easy!) I used equipment that was used for that job and that job only. Some people use gloves but gloves make me clumsy and I just double washed my hands afterward with special attention to my fingernails.

Alison

Wylie's Mom
08-05-2009, 02:48 PM
Hi Nathalie,

So correct me if I have this wrong,
- the first T4 of 1.4 ug/dL (low by Dodds standard) was while on 0.4mg, but the test was done too long after the last dose, and therefore his actual T4 was probably higher.
- the second T4 of 6.29 ug/dL (high by all standards) was while on 0.6mg and the test was done at the proper time

My knowledge/experience of hypothyroid is very limited & brief, but if the above is correct, you really don't know what his levels are at the current 0.4mg dose, so I agree with you that you might want to have him tested again. Some of the low T4 may also be due to Cushing's, so you might find that the T4 may rise some as his cortisol becomes more controlled, but I'm only guessing that that would take some time to happen. Were they able to determine that his low T4 was truly due to Hypothyroid, and not having to do with his Cushing's? I was never able to find a consensus on which of the "T"s could determine that and left the interpretation to my IMS.

-Susy

Nathalie
08-05-2009, 06:40 PM
Hi Susy,

You are correct, while on 0.4 mg his T4 must have been way higher as it peaks during 4-6h post pill. The Geriatric optimum therapeutic level is T4 2.20 – 4.50 g/dL and FT4 0.70 - 2.00 ng/dL (these optimum levels are based on him being on thyroid replacement, age and breed).

Yes, I have no idea where his T4’s are at at this point. I can only make a guess based on his T4 being at 0.6 prior to starting Soloxine and where he was at x-amount of hours post pill and hopefully he is somewhere smack in the middle where he should be.

I am not aware about that it is possible to determine that the low thyroid function is due to cushing’s. It’s the TGAA levels that can confirm autoimmune thyroiditis.
That is why vets are sometimes reluctant to put a dog on thyroid replacement because they falsely believe once a dog is on thyroid replacement the dog will always require replacement.
Per Jean: “The fact that many veterinarians believe incorrectly that once you put an animal on thyroxine, he/she needs to be on this medication for life. In fact, if you stop the thyroxine even after years of therapy, it takes 5-6 weeks for the pituitary-thyroid axis to be reactivated to its original capacity [whether low or normal] .”
I am not sure why, but in Phillips case Jean believes that the low thyroid and the cushings are 2 separate issues. I never asked her about it because this whole loading journey took over everything else.

The way I look at it, considering Phillip’s age I am not putting him through weeks without getting any Soloxine just to find out if he can produce enough on his own unless his test results would indicate so even if we get to the point to have his cushings controlled. I am happy with giving him Soloxine as long as needed and to keep his T4's at a nice level.

We probably to a thyroid test with the next stim.
Nathalie

Wylie's Mom
08-06-2009, 10:33 AM
Hi Nathalie,

Thank you for the thyroid information. After Wylie had a T4 of 0.9 (Dec 08), I had done a thyroid panel through Mich. State U consisting of TT4, TT3, FT4 (by dialysis), FT3 & TSH… TGAA was not included. But based on the panel, the IMS had determined that the low T4 was due to Cushing’s. I don’t know how she determined it, but his last T4 was 1.2 (June 09).


The way I look at it, considering Phillip’s age I am not putting him through weeks without getting any Soloxine just to find out if he can produce enough on his own unless his test results would indicate so even if we get to the point to have his cushings controlled. I am happy with giving him Soloxine as long as needed and to keep his T4's at a nice level.

I agree with you… I’m sorry if it seemed like I was implying that you stop:o. I was just concerned that the symptoms you were seeing (that looked like his cortisol levels were increasing radically), might actually be due to his thyroid levels. And if that is the case, I believe hypertension/hyperthyroid could possibly be more of an immediate concern… and I’m not implying to stop the lyso either… I would just have more peace of mind if his T4 levels are known;). Because of my limited knowledge, I honestly don’t know how much this concern is warranted. Since you are currently loading, you'll probably have a stim done soon, so I think it's a great idea to have his T4 checked at that time... and I'll be anxiously waiting:D.

-Susy

BTW- will having the stim drawing & drawing for the T4 test at the same time work?... I believe the ideal time for the ACTH stim is in the morning, but I wouldn't think that would work typically with the time you'd probably want the drawing for the T4 to be... just a thought. I think the timing for the T4 is more critical... maybe it's not as big a deal to do a monitoring stim test (as opposed to a diagnostic one) later in the day to fit the ideal time for the T4 - Hopefully, someone here will have an opinion on this.

Nathalie
08-06-2009, 02:17 PM
Thank you for the thyroid information. After Wylie had a T4 of 0.9 (Dec 08), I had done a thyroid panel through Mich. State U consisting of TT4, TT3, FT4 (by dialysis), FT3 & TSH… TGAA was not included. But based on the panel, the IMS had determined that the low T4 was due to Cushing’s. I don’t know how she determined it, but his last T4 was 1.2 (June 09).

Well, I can’t recall how old your dog is but if he is an older fellow then a T4 of 1.2 is a bit low by Jean’s standard.
Optimal therapeutic response levels should be in the upper 1/3 to 25% above the upper limits of the resting optimal ranges at 4-6 hours post-BID thyroid medication.
To bad they did not a TGAA – I think it is very valuable to know if it is autoimmune thyroiditis. It would not really change anything I am doing with my Phillip because we don’t do booster vaccination or HW/flea pestices etc. but for anybody who is still doing so, they may would choose not to further compromise the immune system any further and trigger who knows what – just MHO.



I agree with you… I’m sorry if it seemed like I was implying that you stop:o. I was just concerned that the symptoms you were seeing (that looked like his cortisol levels were increasing radically), might actually be due to his thyroid levels. And if that is the case, I believe hypertension/hyperthyroid could possibly be more of an immediate concern… and I’m not implying to stop the lyso either… I would just have more peace of mind if his T4 levels are known;). Because of my limited knowledge, I honestly don’t know how much this concern is warranted. Since you are currently loading, you'll probably have a stim done soon, so I think it's a great idea to have his T4 checked at that time... and I'll be anxiously waiting:D.
-Susy

Oh my, no need to apologize for anyting! :eek:I was just making a statement and while I was writing it I thought about Phillip’s vet who did not want to put him on Soloxine because he may start producing on his own down the road once the cushing’s is controlled etc.etc… I am all for getting to the root of things and having the body produce whatever it needs on its own and not palliating the symptoms but where we are right now, the Phillip get’s whatever makes him feel better now and I can afford. May this be drugs, herbs, food …
I can get quite passionate when it comes to dogs and I know that there are a lot of dogs out there that are on thyroid replacement but are not well regulated because the vets don’t know enough or maybe are not too interested in spending too much time learning and treating the condition – again that is just my opinion.
Just the other day I saw this dog, moving very slow, overweight. So I talked to the owner because the dog just did not look ‘right’. Turns out the dog has been on thyroid replacement for the past 6 month with very little improvement. Turns out – she was told to pill only once per day with food. Poor dog – he has been going through daily up and downs needlessly. When they did the last thyroid test they did it 19h post pill – that is just a sad state of affair as far as I am concerned. Since our talk the owner started pilling every 12h,
1h before or 3h after feeding and will make sure the test is being done at the right time. ;)

Phillip is going in for a stim and thyroid test on Monday because his vet starts vacation on Monday but offered to come in to do the blood draws anyway and retrieve the test results on Tuesday – which I thought is very nice.
Hopefully he loads by Saturday. So far there has been no change in his appetite. BUT, he has perked right up. This morning I took everybody to the park and we walked for 2h and he had a nice spring in his step, did a puppy run and was very bright eyed and alert. He rolled in some coon poop so I had to get him into the deep water to wash some of that stink off. Now, I can’t just tell him to go for a swim or fetch a stick out of the deep water (my hounds just don’t see the point in retrieving anything and unless it has a bushy tail will not chase it either). So I started throwing treats in the water …. It was great .. the fellow was swimming to get to the treats so I just kept on throwing the treats. I will now do this every time we go to this particular park – we can do hydrotherapy for his hind legs right there for free.

Anyway, sorry for the long post. I am on vacation right now – back to work on Tuesday. Once I am back at work I promise the post will get shorter again.:)

Nathalie

Harley PoMMom
08-06-2009, 02:27 PM
Nathalie,


Just the other day I saw this dog, moving very slow, overweight. So I talked to the owner because the dog just did not look ‘right’. Turns out the dog has been on thyroid replacement for the past 6 month with very little improvement. Turns out – she was told to pill only once per day with food. Poor dog – he has been going through daily up and downs needlessly. When they did the last thyroid test they did it 19h post pill – that is just a sad state of affair as far as I am concerned. Since our talk the owner started pilling every 12h, 1h before or 3h after feeding and will make sure the test is being done at the right time. You are an amazing person, so kind, loving and caring...when I read this...it brought tears to my eyes...what a wonderful person you are to share your knowledge with others so their babes will benefit.


Anyway, sorry for the long post. I am on vacation right now – back to work on Tuesday. Once I am back at work I promise the post will get shorter again.No way...I love reading your post...please don't make them shorter.:(

Love and hugs.
Lori

Wylie's Mom
08-06-2009, 07:58 PM
Hi Nathalie,

My pup is a “geriatric” 12 yr-old:D. I had thoughts of treating Wylie for Hypothyroidism again (even though his IMS vet believes the low levels are due to Cushing’s), just a tiny boost, and stop when or if tests reveal that he doesn’t need the boost anymore… if I do decide to do this, in light of what happened the last time he was on soloxine, I would start very low and work the doses up instead of the way it was done last time (starting at 0.7mgBID, then to 0.5mg BID);). Just to be clear, regarding Dodds optimal levels that you had posted - those levels are the “upper 1/3 to 25% above the upper limits of the resting optimal ranges” that she suggests, right??... meaning a T4 in the upper 1/3 equals 2.2 and 25% above the upper limits equals 4.5, right?

That is great that you were able to help that poor pup, my former vet may have missed Wylie's Cushing's dx, but they did prescribe the soloxine correctly and made sure the T4's were tested 4-6hrs after last dose!

I'm so glad Phillip is perky, I love seeing that "feeling good" trott:p. I don't know about the treat in water thing... I live by a lake and Wylie got giardia once (and he doesn't even swim in the lake). I don't know if your park water is a stagnant lake like mine, or a running stream... but you know, sometimes dogs that have rolled in coon poo might take a swim in it:eek:;):p:D.

-Susy

Nathalie
08-06-2009, 08:51 PM
Thanks for the kind words Lori and don't cry ;)

Share the knowledge and experiance that is what you guy's do here. You all provide a very important service.
Besides, I can't keep my mouth shut when I see something wrong - just can't help it. :p

So, thanks for being there right back to you.
Nathalie

Harley PoMMom
08-06-2009, 09:07 PM
Share the knowledge and experiance that is what you guy's do here.It's easier here, we're all family, I don't know if I could do that with a complete stranger face to face. :eek:

Nathalie
08-06-2009, 09:40 PM
Hi Susy,
Did not want to call anybody’s dog ‘geriatric’ unless I am sure. I used to get so angry when people called my Phillip senior when he was only 8 years old because he started graying in his face pretty early.

Oh, I assumed Wylie is currently on thyroid replacement – sorry, my mistake.

The Geriatric Optimal Levels are …

T4 1.20 – 3.00 mg/dL FT4 0.70 - 2.00 ng/dL
T3 40 – 70 ng/dL FT3 1.6 - 3.5 pg/mL

The Geriatric optimum therapeutic level of T4 2.20 – 4.50 ug/dL and FT4 0.70 - 2.00 ng/dL is I am pretty sure for a dog that is currently being on thyroid replacement.
Yes, these are the “upper 1/3 to 25% above the upper limits of the resting optimal ranges”

A healthy geriatric dogs levels should be at least 1.0 µg/dL for T4 and 0.7 ng/dL for FT4.

So your Wylie is just a bit above the min level. But, there also has to be a good reason why Jean states that these min levels are for a ‘healthy’ dog, which a cushings dog certainly is not.

The suggested dose is 0.1mg per 15 lbs twice daily to start - then test response. So unless your dog weigh’s at least 105 lbs, 0.7 would be too high to start off.

Why don’t you just email Jean and ask her for her opinion. She is amazing – if she is around and is not away teaching she usually gets back to me withing a day or two. Last time I emailed her she was teaching somewhere and she apologized for the delay in getting back to me - wow.
Here is the link to her contact info: http://www.hemopet.org/contact.html

Nathalie

AlisonandMia
08-06-2009, 10:28 PM
Just the other day I saw this dog, moving very slow, overweight. So I talked to the owner because the dog just did not look ‘right’. Turns out the dog has been on thyroid replacement for the past 6 month with very little improvement. Turns out – she was told to pill only once per day with food. Poor dog – he has been going through daily up and downs needlessly. When they did the last thyroid test they did it 19h post pill – that is just a sad state of affair as far as I am concerned. Since our talk the owner started pilling every 12h,
1h before or 3h after feeding and will make sure the test is being done at the right time. ;)



Oh - good on you! This poor dog should be feeling a lot better soon.

Isn't it interesting how once you've had a dog with a certain disease you get quite a good eye for it? I was at the vet with another animal (one of my birds I think) and I saw a little dog and I thought she looked a tad cushingoid - not full blown, but just a bit. So I got to talking to the owner and found that the little thing was only just over a year old and had had little white shaker disease and was on the tail end of a longish tapering course of prednisone to treat this disease. Ha! I knew that "look"! Makes you wonder how Cushing's gets missed so often. (BTW, the treatment was successful and the guy who owned her said he'd driven across town to see this vet as another vet had told him his pup's condition was untreatable and he should have her put to sleep.)

I'm not sure I'd recognize a hypothyroid dog like you would! I'd probably just think it was "old" and then start wondering about something else over the next couple of days.:rolleyes:

Alison

Nathalie
08-09-2009, 08:17 PM
I hear you Alison – when at the park I am looking for pot-bellies, hyper-pigmentation etc. – I just can’t help it. :)

It’s beyond me how cushings and hypothyroid can get missed or misdiagnosed so often. In Phillip’s case he looked like and had a lot of the symptoms of a typical cush dog. Knowing what I do today – it would be a no-brainer diagnosing him just by looking at him. But hey – then I am not a vet :rolleyes: ;)


Tomorrow Phillip is having another stim and thyroid test done. I stopped the Lyso yesterday so he has had 5 days of 1500 mg per day.
I doubt very much that he is loaded – but hope that I am wrong. I know the cortisol has been going down because his hind leg pressure sores are getting inflamed again. Perhaps his body is getting used to having less cortisol circulating and that is way I am not seeing a huge difference in his appetite???

I keep on pondering over his past stim test results and responses to the different doses of Lyso (http://www.k9cushings.com/forum/showthread.php?t=615&page=14). …… to determine what a good maintenance dose would be if he is loaded. On the other hand I don’t think we have enough numbers yet to truly be able to make an analysis yet.

When I talked to his vet she feels putting him on 75 mg per kg would be a good maintenance dose at this point in time. Phillip weights about 29 kg = 2175 mg.
To keep it simple I could give him 4.25 tabs per week = 2125 mg.

Does this sound like a good plan?

Nathalie

Nathalie
08-10-2009, 06:08 PM
Bumping this up as I have to talk to Phillip’s vet tomorrow morning and discuss stim test result and how to proceed/ dosing of lyso and I won’t be able to speak to her again for at least a week after since she will be away on vacation. Please see my last post.

Also, he had too much fat in his blood (fasted for 13h and no change in diet) so she could not run the T4 test herself. I read Leslie’s last post about Squirt too having too much fat in his blood and possible Hyperlipidemia. This is the first time this happened – is this something to be concerned about now? Any feedback would be appreciated.
Thanks,
Nathalie

AlisonandMia
08-10-2009, 06:19 PM
One reason for fat showing up in the blood - especially if it can be seen just looking at the sample - is pancreatitis.:( Has the vet had a look at his amylase and lipase levels (these enzymes are usually elevated with pancreatitis)?

Whatever is the cause of this fatty sample after 13 hours of fasting, it looks like he probably doesn't tolerate much fat in his diet so doing with the 75mg/kg dose for maintenance (and keeping his diet as it has been - fairly low fat) is probably going to be necessary to get the right amount of Lysodren into him. (Kim's (Frijole) Hayley is on a comparable maintenance dose if I remember rightly). I take it you plan to do another stim after a month on the new maintenance dose to make sure it is holding things stable?

Is it possible he somehow managed to sneak something to eat when he was meant to be fasting - like found an old bone and got some marrow out of it or something?

Alison

Harley PoMMom
08-10-2009, 06:45 PM
I found this on the merck vet manual web site:

This can be primary or secondary to hypothyroidism, pancreatitis, hepatic disease, diabetes mellitus, nephrotic syndrome, hyperadrenalism, or high-fat diets. Hyperlipidemia is present when blood lipids are increased with or without gross lipemia and probably results from abnormalities in the synthesis or use of plasma lipoproteins. In primary hyperlipidemia, the abnormalities can be familial and might be genetic, as has been suggested in Miniature Schnauzers. Some dogs with hyperlipidemia are asymptomatic. Clinically affected dogs may have recurrent seizures, depression, recurrent pancreatitis, vomiting, acute blindness, corneal opacity, and xanthogranulomas. The goal of dietary management is to decrease the digestion and absorption of fat by feeding a diet restricted in fat (<10% dry-matter basis). The use of fish oil capsule supplements at a dosage of 1 g/4.5 kg body wt either once a day or in divided doses, depending on the number of capsules needed, help reduce serum triglyceride concentrations. Although fish oil supplements generally do not return serum triglycerides to normal values, partial reduction is believed to mitigate the risk of pancreatitis or other problems related to marked elevations of this lipid.

http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/182907.htm

Love and hugs.
Lori

Nathalie
08-10-2009, 07:23 PM
One reason for fat showing up in the blood - especially if it can be seen just looking at the sample - is pancreatitis.:( Has the vet had a look at his amylase and lipase levels (these enzymes are usually elevated with pancreatitis)?

Pancreatitis – yikes – he had a bout of what I thought a terrible stomach upset around last October or November after putting everybody on kibble for a few months. Once he started eating again I went back to feeding raw and he was fine. The kibble was probably way higher in fat and pancreatitis back then.

No, she did not say anything about amylase and lipase levels.:(:( And no, he did not sneak anything in those 13h.
Is this something that requires action right NOW, such as sending another blood sample to check his amylase and lipase levels or can this wait until the next stim test in a month, assuming he is loaded?

Thanks for the info/link Lori. I am terrible when it comes to figuring out anything diet related – will have to email the people at Urban Wolf once I read through the info (tried going there but browser freezes - time for a reboot).

But how would I know the right daily amount of fat to feed to aid in Lyso absorption and at the same time prevent pancreatitis?

Thanks,
Nathalie

Harley PoMMom
08-10-2009, 07:30 PM
Nathalie,

Everything that was on that web page, I pasted on your thread, I just wanted to show you where I got the info.

Love and hugs.
Lori

Nathalie
08-11-2009, 12:47 PM
Well, we did not get much sleep last night because Phillip was panting like crazy even so he was right in front of the air vent with the AC running all night. He also was very itchy (front paws and hind legs) and he kept on licking his pressure sores on his hind legs which started to look very inflamed – so for the first time I also had to bandage his hind legs. I kept on checking on him until 1am and he was still awake and not feeling well. So instead of phoning the vet I just took him in at 9am (today supposed to be my first day back at work after being off for the past week – yikes)- I wanted her to check him over and also look for any signs of pancreatitis.

Last week I said I would be very surprised if he is loaded. Well, he is loaded and am I ever glad I stopped the Lyso even so there was not a big change in his appetite – after 5 days of loading I just felt he had enough based on his demeanor and the huge increase of tremors in his hind legs.

Stim results:

Pre: o.833 (23)
Post 2h: 1.59 (44)

The test was done 38 h post last Lyso dose so I think his cortisol could have been even a bit lower last night around the 48h mark and that is why he felt so lousy.
We gave him 1 prednisone to make him feel better. Phillip seems to feel the best at the higher end of the range.
I am supposed to give him 1500 mg of Lyso this week (Thursday, Friday, Saturday) and then continue on 2000 mg for the next 3 weeks with a follow-up stim test.

The vet did palpated his stomach and feels that at this point there are no signs of pancreatitis. We could do a blood test that is fairly new (forgot the name) but she does not think it is warranted at this point in time.

His T4 came in a bit low at 1.81 (23.3), should be between 2.20 – 4.50 mg/dL but I think it is better to leave him on his current dose, try to get the cushings regulated first and then retest the T4 with the next stim test.

Now if I only could learn not to panic right away. :o:o:o
Nathalie

Squirt's Mom
08-11-2009, 01:04 PM
Now if I only could learn not to panic right away.

If you figure this one out, could you pass it on to me? :p

lulusmom
08-11-2009, 01:22 PM
Hi Nathalia,

It is a very bad idea to give the maintenance dose on consecutive days. Lulu's IM had me dose her once a day for three to four days when her post stim was too high. Even with a low dose given on consecutive days, Lysodren will actively erode the adrenal cortex. Since Phillip's last post stim was pretty low, you run the risk of overload and making him sick. The whole idea of maintenance is to maintain the erosion level achieved through loading and this is more effectively done by spreading out the maintenance dose like say, Mon, Wed & Fri. That's just my two cents.

Glynda

Nathalie
08-11-2009, 05:45 PM
Hi Glynda,

Considering he was so low on Monday (Pre: o.833 (23), Post 2h: 1.59 (44))when we did the stim and I gave the last loading dose of Lyso last Saturday night and I am supposed to give him 1500 mg (3 pills) this week and starting a maintenance dose of 2000 mg (4 pills) as of next week how am I supposed to do this other then giving on consecutive days this week? :confused:
I don’t want to give him any Lyso today to get the cortisol up a bit. That leaves Thursday, Friday Saturday to give the 1500 mg and then start a Monday, Wednesday, Friday, Sunday schedule to give 2000 mg weekly.

Unless you guy’s think that giving 1500 mg this week is too much? Would it be better all things considered to give him only a total of 1000 mg, pilling Thursday and Saturday of this week?

Nathalie

AlisonandMia
08-11-2009, 06:11 PM
When did he have his last Lysodren dose?

It might help to, rather than think in weeks and weekly doses at this time, to think in doses and start him on his 2000mg dose (4 pills per week now) with giving one pill every couple of days from the day you want him to start on maintenance - and take it from there. After all his adrenals don't know anything about "weeks" - what affects them is the amount of Lysodren in his system on a day-to-day basis. I do share Glynda's concern about giving him a big slug of three doses on consecutive days at this point considering how low he is at the moment.

Alison

Nathalie
08-11-2009, 06:55 PM
When did he have his last Lysodren dose?

It might help to, rather than think in weeks and weekly doses at this time, to think in doses and start him on his 2000mg dose (4 pills per week now) with giving one pill every couple of days from the day you want him to start on maintenance - and take it from there.

Alison, his last dose was on Saturday, 750 mg with breakfast and 750 mg with supper. What I would like is the cortisol to rise just a bit – he felt so lousy last night. :( Since we gave him the pred this am I can see a definite improvement. I am totally open to suggestions. When would you give him his first pill?



After all his adrenals don't know anything about "weeks" - what affects them is the amount of Lysodren in his system on a day-to-day basis. I do share Glynda's concern about giving him a big slug of three doses on consecutive days at this point considering how low he is at the moment.

Alison

Nope, I am certain his adrenals don’t come with a calendar :D:D:D

I sure appreciate your concern! If you guy’s are concerned, I am concerned.

Thanks,
Nathalie

AlisonandMia
08-11-2009, 07:08 PM
I'd wait at least until he doesn't seem to need the pred to feel good. Each dose of pred lasts approximately 24 hours so if he still needs it you'll see it wearing off at some stage around that time.

Once he seems ok without the pred I'd give it another 24 hours to be sure and then start maintenance then.

It looks like Phillips adrenals regenerate pretty quickly like Mia's did. At one point I realized that although her numbers were within the desired range as per a stim test that she wasn't bouncing quite as high as usual - ie her muscles were maybe not quite up to full strength although I'm sure she felt fine. I delayed a dose by 24 hours and her peak strength returned and then we went back to the normal dosing and she maintained that strength from then on. (Of course with Phillip still having weakness from the Cushing's itself this particular sign probably won't be a great indication for you at the moment.)

I should add that although Phillip's adrenals appear to regenerate rapidly now this may change as he ages - or it might not. Often you get used to how they are and then something changes probably as a result of aging.

Alison

acushdogsmom
08-11-2009, 07:32 PM
I agree with what Alison and Glynda said, as usual. :D

It's really hard to say when is the right time to start maintenance dosing for each individual dog ... you don't want to start before he's ready (you may want the cortisol production to come up just a little bit and you want him feeling better and not needing the pred to feel okay) but you also don't want to let the cortisol creep up too high before starting the maintenance dosing. If only we could check their cortisol levels the way we can check blood sugar of a diabetic, with a little hand held meter at home!

My Vet had us wait a week or so (it could have been 10 days, I don't remember) after the loading was complete before starting with the maintenance dosing.

Nathalie
08-11-2009, 07:41 PM
I'd wait at least until he doesn't seem to need the pred to feel good. Each dose of pred lasts approximately 24 hours so if he still needs it you'll see it wearing off at some stage around that time.

Once he seems ok without the pred I'd give it another 24 hours to be sure and then start maintenance then.

Sounds like a sensible plan Alison.



It looks like Phillips adrenals regenerate pretty quickly like Mia's did. At one point I realized that although her numbers were within the desired range as per a stim test that she wasn't bouncing quite as high as usual - ie her muscles were maybe not quite up to full strength although I'm sure she felt fine. I delayed a dose by 24 hours and her peak strength returned and then we went back to the normal dosing and she maintained that strength from then on. (Of course with Phillip still having weakness from the Cushing's itself this particular sign probably won't be a great indication for you at the moment.)

Yes, it is not a good indicator at this point. BUT, if I ever see him this wobbly in the hind end again I will delay a dose and see how he does within the next 24h. This is good to know.



I should add that although Phillip's adrenals appear to regenerate rapidly now this may change as he ages - or it might not. Often you get used to how they are and then something changes probably as a result of aging.


I am going to make a mental not of this. What I actually need to do is go through the whole thread and compile all the great information that has been given to me by everybody into one document for later reference.

Again – thanks a million!
Nathalie

Wylie's Mom
08-13-2009, 11:28 AM
...even so he was right in front of the air vent with the AC running all night. Wylie used to lie in front of the vent and lick it like it was a popsicle.


His T4 came in a bit low at 1.81 (23.3), should be between 2.20 – 4.50 mg/dL but I think it is better to leave him on his current dose, try to get the cushings regulated first and then retest the T4 with the next stim test.


I am so relieved that the T4 wasn't too high - I completely agree with keeping this dose for now AND holding off on the lysodren until he doesn't need the pred is an excellent approach. I just wanted to let you know that the hind end tremors doesn't seem to be a sign of low cortisol for Wylie, but of course, every dog is different;).

And thank you for the thyroid information... I'll probably have the T4 checked again with his next stim, too.

I really hope this new maintenance dose works for Phillip!

-Susy

Harley PoMMom
08-14-2009, 12:58 PM
Hi Nathalie,

How is Phillip feeling today?

Love and hugs.
Lori

Nathalie
08-14-2009, 07:38 PM
Hi Guy’s,

Phillip has perked up again – he still has hind leg tremors from muscle loss but that’s nothing compared to Monday/Tuesday. He got his spring back in his step and already started eating things that lets say, 'have been around for quite some time' again – time to start maintenance.
It has been 5 full day’s since the last loading dose, 60h since I gave him a pred on Tuesday morning and I gave him his first 500 mg of Lyso last night. So glad you guy’s stopped me from giving him the suggested 1500mg of Lyso this week!

Good thing dogs don’t have any hang-ups about the way they look. He has lost almost all of his top coat and around his bum he looks like someone did a bad hack job – but he keeps on shedding.
Any idea when the hair loss will stop and new hair starts growing in? It would be nice if he could grow at least some of his top coat back before winter comes … he is not really a coat type of guy.
Heat intolerance, any idea when I can see an improvement? The poor guy has been living in my small kitchen for the past view months because it has a cool tile floor and a big air vent. I feel sorry for the guy being somewhat isolated in there.

I “think” I figured out why I did not see the same amount of decrease in appetite during the second load .. Last time around he was getting too much Soloxine which made him Hyperthyroid which probably further decreased his appetite in addition to the effect the Lyso had.

I have a good feeling about his new maintenance dose of 2000 mg. Perhaps it is only wishful thinking but then this could be it.

Oh, and the price for his stim test just ‘went down’ … some of you may remember that his vet insisted doing a post 1h and 2h draw. I thought it was a flat rate for the stim so I just went along with it. Well, last Monday we only did a pre and a post 2h draw because she was on vacation and only came in to do the test and I did not feel like lugging the all the dogs back and forth 3 times so she agreed to do only 1 post draw. When I checked the bill the cost went from $142 to $89. Needless to say from now on we are only doing 2 blood draws. This will make a huge difference in the long run. :)
Nathalie

Roxee's Dad
08-14-2009, 09:24 PM
Hi Nathalie,
Great to hear the good news on Phillip.

In my experience, Roxee always prefered the cool floor or to lay under the fan even when her cortisol was under control.


I have a good feeling about his new maintenance dose of 2000 mg. Perhaps it is only wishful thinking but then this could be it.

Trust your gut feeling, you know your boy best. Numbers are always a good reference but every pup is different and nobody know him better than mom.

AlisonandMia
08-15-2009, 10:58 PM
Good thing dogs don’t have any hang-ups about the way they look. He has lost almost all of his top coat and around his bum he looks like someone did a bad hack job – but he keeps on shedding.
Any idea when the hair loss will stop and new hair starts growing in? It would be nice if he could grow at least some of his top coat back before winter comes … he is not really a coat type of guy.
Heat intolerance, any idea when I can see an improvement? The poor guy has been living in my small kitchen for the past view months because it has a cool tile floor and a big air vent. I feel sorry for the guy being somewhat isolated in there.



It is a good thing that they don't care a bit about how they look (as long as they smell right, that is.)

This is my experience with coat weirdness and Cushing's:

As you can see from my avatar (which is a pre-Cushing's pic of Mia) she had very smooth fine coat. When she developed Cushing's (which she did pretty rapidly and decisively and at the most went 8 months from the very beginning of onset to treatment) she lost a bit of hair but it wasn't particularly marked as her normal coat was so sparse and fine anyway. She, like most dogs with her coat type, was one to shed a bit all the time without ever really blowing her coat or anything. If you picked her up she always left you with a few white hairs. Once the Cushing's started that shedding stopped - in fact, in retrospect, that was a very early sign that something was up with her.

Once she was treated (Lysodren) she blew her original coat and seemed to shed all her skin in a shower of dandruff and grew this awful, thick fluffy fright-wig of a coat. It was in October (late spring here) that this happened and I remember thinking that she'd grown her own Halloween costume! Her white fur was now flecked with black (that would have been hyperpigmentation caused by the pituitary tumor) and what had been her black fur was a weird brownish/greyish color. The coat itself was a very thick, hot sort of fuzzy under coat and I had to get her clipped all over for the summer. The groomer said her clippers kept getting "bogged" the coat was so thick.

She never seemed to lose any fur after that - no shedding - but the coat did keep growing and by late summer she was feeling the heat because of it. Rather than have her clipped again, with winter coming on, I had the vet shave her belly (as they would for an ultrasound) and that seemed to give her tremendous relief. Mia was a very fit and active little dog and liked nothing more than hour+ walks where, because of her little doxie-type legs, she ran all the way, so keeping her cool was important.

She went through that winter with her clipped belly (which was getting hairier as she grew some weird, wiry guard hairs) and the her "husky coat" kept her pretty warm although she happily wore her coat at night and on colder days - she only weighed about 4.5kg.

Next spring I got her clipped again and she looked and felt great. Throughout that summer the clip went on getting subtly more untidy (although not quite at the rate it did the year before) which must have meant there was some hair growth going on. And still no visible shedding - if I stroked her firmly with a rubber glove all I got was one or two small fuzzy hairs stuck to it.

Unfortunately Mia passed away at the end of last summer due to a brain tumor unrelated to her Cushing's. Her little body remained fit and strong right to the end and until about three weeks before she passed she was enjoying long, daily walks (runs for her) and keeping her cool pretty well. Brisbane's climate is pretty comparable to Florida's so with the heat and humidity in summer I did walk at night both for the dogs' sakes and for mine. With her little black head Mia always really felt the effects of direct sun. (I've got really dark hair so I knew what she was going through!)

One thing I have no idea about is whether this coat weirdness that so often happens with Cushing's dogs is caused by the physiological upset of changes in cortisol level (which is what I assumed at first) or whether it has something to do with the pituitary tumor itself. Horses with Cushing's grow a long shaggy, non-shedding coat (it's one of the main signs in horses) and in horses this abnormal coat is ascribed to the pituitary tumor itself rather than the cortisol level. I'd love to know if a smooth coated dog (like, say, a beagle) which has been successfully surgically treated for an adrenal tumor, has the same long-term coat problems. Beagles and other smooth-coated dogs with pituitary Cushing's most certainly seam to and, like Mia, usually end up needing clipping if they live in a hot climate. People with poodles and bichons often say that their dog's coat is better and more luxuriant than ever once the Cushing's is treated.

If Phillip is feeling the heat now and you are unwilling to clip him considering that summer is coming to an end you could consider having just his belly shaved - they seem to lose a lot of heat through their belly. Of course he'll look seriously strange - but like you said that won't worry him and it might help him keep more comfortable.

Alison

PS: Mia's post-Cushing's coat was not particularly water proof (it was so fluffy) and if she got wet in the rain on a walk I had to blow dry her - otherwise she would have stayed wet for hours and hours because her coat was so thick. My cattle dog could just shake himself off and be fine.

I'll post some pictures soon.

Nathalie
08-26-2009, 06:41 PM
Quick update on the Phillip ….... not to worry - no crisis or meltdowns happening here .... at least not today :p

He has had a tough time last week and I had to skip a dose of Lyso and gave him a pred. Aside from just not ‘looking right’ he also became paranoid of flies. He hates everything that buzzes around but on Saturday he was actually staring into space as if there was a fly or wasp in the house and van where there absolutely was nothing and hide in the bedroom.

Cortisol must be up a bit because since yesterday he is feeling GOOD again. I would love to know at what level he feels well. If someone would invent a 'cortisol meter' for home use they probably could make big money.

Here are a couple of video clips of him swimming to get cookies – not so good quality but this is as good as it gets with my old cam.

http://s226.photobucket.com/albums/dd165/nathaliesaskia/


To me he looks and feels like a big teddy bear all soft and fuzzy since he has lost all of his top coat. A friend of mine came over for a visit and had not seen him in months and commented on how good he looked – very encouraging. :)

Alison, I would love to see some pictures of your Mia whenever you get a chance to upload them. ;)

Nathalie

Harley PoMMom
08-26-2009, 08:37 PM
Nathalie,

Awww...he is so precious and he loves, loves the water...he's such a good swimmer too. :)

Thanks so much for sharing the videos...good job...I loved them.

Love and hugs.
Lori

frijole
08-26-2009, 09:46 PM
Nathalie, Those videos were great. It is fun to capture his personality... I feel like I know him. Hugs from our house and thanks for sharing. Kim

Roxee's Dad
08-26-2009, 10:39 PM
Hi Nathalie,

Great video:D


Cortisol must be up a bit because since yesterday he is feeling GOOD again. I would love to know at what level he feels well. If someone would invent a 'cortisol meter' for home use they probably could make big money.

I think Beth is working on one :p

Glad all is going well with Phillip.:)

Nathalie
09-21-2009, 12:41 PM
Phillip's stim results are back …

Pre: 1.9 (52)
Post: 6.23 (172)

It has been 6 weeks since loading
5.5 weeks on maintenance (skipped one pill during the first week) and 4 full weeks on maintenance of 2000 mg of Lyso per week.


His appetite started going up a bit during week 3 (the same happened last time after loading), water is up a bit. He has gained a couple of pounds and weighs now around 63 lbs (hard to say his exact weight as the scale at the vets gives different results every time). He now has a thick fluffy/shiny coat and has stopped shedding excessively. He seems to be feeling quite well and the vet thinks overall, considering him being 12 now, this as good as it will get – I was hoping that his energy level would go up a bit more.

The numbers are not bad I think but I am worried that they will creep up even more … I would be more then happy if we could keep him at this level.

The vet suggested increasing the Lyso by 250 mg which would mean he would be taking 2250 mg per week.

I suggested to suspend the 2000 mg of Lyso in oil and see if this will keep the numbers stable. BUT, I really don’t want to have to do a mini-load again in case suspending in oil does not do the trick.

What would you guy’s do?
Right now I am leaning towards increasing the Lyso because reloading just simply scares me (last time he could have crashed if I had given him 1 more pill)

Thanks,
Nathalie

frijole
09-21-2009, 08:34 PM
Natahlie, I had to think on this a bit... because like you I wouldn't want to have to reload. My biggest concern is that you indicated you noticed some symptoms returning after week 3.

Since you are a hawk I trust you will keep a close eye out. So give the oil a shot and see if you see a reduction in the symptoms. If you don't you might try increasing the dosage.

I'm curious what others have to say. And you are right - the numbers aren't horrible.. it's the creeping we all need to be careful of.

Hugs,
Kim and girls

lulusmom
09-21-2009, 10:36 PM
Hi Nathalie,

I have a horrible memory and I don't want to re-read your entire thread so would appreciate it if you can tell me what food Phillip on and do you give him his Lysodren with something fatty like cream cheese?

My Lulu's post stim was 6 point something and we upped her dose a bit and her next post stim was almost perfect...4.65. That is a little too high for comfort and would much prefer somewhere in the 3 range. I love wiggle room. :D I also switched from giving the meds with peanut butter to cream cheese to increase the fat a bit. It is a messy and time consuming proposition to heat corn oil, crush the tablet, etc. I think both options will work but you are so darn close, I personally would go with the increase in dose. If the post stim number was a bit higher, I would probably try the oil but I honestly think that the increase will do the trick.

Glynda

AlisonandMia
09-21-2009, 10:39 PM
I'd give the suspending in oil thing a go - as long as he tolerates the oil ok. It does look like Phillip may not be absorbing the Lysodren all that well - or it could be that he really does just need an unusually high dose to keeps his adrenals in line. Either way, suspending it in oil should mean that he gets a bigger dose. That is more or less what I did with Mia's Lysodren and she held very stable once we got the Lysoden/fat/oil dose right. (Because Mia was so little and those pills are so big it was easier to tweak her dose using fat/oil rather than giving more Lysodren. To give her 50mg/kg she had 1/5 or a pill so going to 1/4 would have been a 25% increase which neither the vet nor I liked the idea of.)

I guess at the moment you are aiming at stopping the numbers actually rising any further - is that right? And you are going to get a stim in a month to see if his numbers are heading down (in which case you'd want to reduce the dose a little to hold him stable) or, heaven forbid:eek: check they haven't continued to rise?

If this new dose (with the oil) does hold him stable then, if you decide that he is still a tad symptomatic at around 6 on the post, then you could do a mini load and then resume using that dose. I know my Mia would not have been at her best at 6 but some are (especially when they are not so young and/or have allergy issues) - it's an individual thing.

Alison

PS: Just read Glynda's response (on previous page) and she's right, messing around with oil and Lysodren does sound like a real, messy hassle. What I did was grind up the dose and then roll up a teaspoon of full-fat cream cheese and pour the powder into a divot I made in the ball, then I'd mold the cream cheese around it sort of like a pill pocket. I also added a capsule of fish oil to the meal she had. I never actually suspended anything in oil - it seemed too much like messy hard work to me - but I think what I did had pretty much the same effect. One of the reasons I ground up the dose was that 1 in 5 doses had to be ground anyway (I was dividing 500mg tabs into 1/5's) so, to be consistent, I ground up every dose and it probably did maximize the absorption.

Nathalie
09-22-2009, 07:17 PM
Thanks for the input – it really helps to hear different views. Mine seems to be controlled by what I would like to see happening rather then what needs to be done at first when it comes to my own dogs. :)

Glynda – Phillip is on a pretty lean raw diet. I don’t want to increase the fat in his meals as he does not cope very well with what is too much fat for him.
I am giving the Lyso with about 2 tabelspoons of peanutbutter all rolled in a slice of white bread. Recently I started adding about 1 teaspoon of Hering oil.
I can only guess that the problem might be a combination of the low fat in his diet as well as him just being one of those dogs that need a higher dose.

Yes, I really don’t want to have to mess around with heating oil etc. – give me a headach just thinking about it.

Alison, when I read your reply I remember a previous post of yours where you said something to the effect that there is only an adequate, insufficiant or to high a maintenance dose. …. ;)

So here is what I am thinking …

Before he was on 1500 mg per week - after 3 weeks he became symptomatic and his post stim was over 7.2.
After a mini-load we put him on 2000 mg and after 4 full weeks on this dose his post stim was 6.2

His appetite is goining up as we speak and today I noticed that one of his eyes is starting to tear again (tearing eyes was one of his symptoms), water intake is going up and he had go out for a late night pee.

At a post of around 7 he starts snacking on poop. :eek:

So I think the goal needs to be to bring his numbers down a bit and I don’t think an increase of 250mg per week will do the trick. So what I am going to do is increase by 500mg per week for a total of 2500 mg per week (The vet originally suggested to increase by ½ - 1 tab) and do a stim test in 4 weeks or sooner if needed.
Alison, I think you called this a low-dose load in your previous post.

This should hopefully bring the numbers down and then maybe we can maintain his numbers by cutting back to 2250 mg per week.

Today I looked for a pill crusher but did not get lucky so what I am doing for now is cutting the pills in quarters, soak in fish oil (letting it sit for a bit so it can soak into the pills) and wrap in peanutbutter and bread.

Does this sound like a good plan?

Thanks,
Nathalie

ventilate
09-22-2009, 07:37 PM
Hi;
I have a couple questions. When you did your miniload did you stim right after? is it possible that the miniload did not bring the cortisol down much at all and the maintenance dose is actually bringing it down slowly?
I would be concerned if you did not do a stim after the miniload that increaseing the maint that much could be to much.
Watch the fats, as I am sure you know cushdogs are prone to pancreatitis.

just my thoughts
Sharon

Nathalie
09-23-2009, 08:03 AM
Hi Sharon,



When you did your miniload did you stim right after? is it possible that the miniload did not bring the cortisol down much at all and the maintenance dose is actually bringing it down slowly?
I would be concerned if you did not do a stim after the miniload that increasing the maint that much could be to much.

Stim test results before doing the mini-load:

Pre: 2.86 (82)
1h: 6.52 (180)
2h: 7.5 (201)

We put him on 2500 mg for one week to do a low-dose load but at the end of the first week he started eating poop and we started a mini-load of 1500mg per day for 5 days. The stim test was done 36h after the last dose and the result was ..

Pre: 0.883 (23)
2h: 1.59 (44)

After loading I waited 4.5 days before starting him on a maintenance dose of 2000 mg.

Most recent stim test:

Pre: 1.9 (52)
Post: 6.23 (172)

So if I am analyzing the numbers correctly 2500mg should bring the numbers down a bit and hopefully 2250mg will be a sufficient maintenance dose???? Or, am I looking at this the wrong way?:confused:


Thanks,
Nathalie

Nathalie
10-21-2009, 01:42 PM
I could use some input here ... controlling Phillip’s cortisol seems to be impossible :(

After his last stim came back a bit high 1 month ago ...

Pre: 1.9 (52)
Post: 6.23 (172)

I put him on what supposed to be a low dose loading dose of 2500mg per week (before the last stim test he was on a maintenance dose of 2000mg per week) hoping it would lower his cortisol a bit.

No such luck, we did a stim test yesterday, after being on 2500 mg for full 4 weeks, and his pre was 3 and the post was 7.
He was not doing bad until the start of week 4 when he started to eat poop again and his hind legs got very shaky (just as bad as before we started treating with Lyso).

The vet suggested to up his dose again to 3000 mg per week hoping to decrease the cortisol and re-test in 3 weeks.

The question is how much Lyso can you give a dog that weights 63 lbs without causing more harm than good?

Vet suggested ultrasound to see if he has an adrenal tumor etc. as well as full blood panel to see if there is something else going on.

Added:

I had some time to think his numbers/response to the Lyso over while taking the dogs for a walk and hopefully someone could give me same feedback on it.

In August we did a mini-load of 1500mg per day for 5 days.

Stim Test :
Pre: 0.883 (23)
2h: 1.59 (44)

Then we increased the maintenance dose from 1500mg to 2000 mg per week (started new maintenance dose after 4 days after post last mini-load dose).

Stim test results after 4 weeks:

Pre: 1.9 (52)
Post: 6.23 (172)

We put Phillip on a low loading dose of 2500 mg per week

Stim test results after 4 weeks:

Per: 3
Post: 7

Even so 2500 mg did not reduce cortisol production it only went up 0.7 over the course of 4 weeks compared to an increase of 4.64 in the 4 weeks following the mini-load while on 2000 mg (keeping in mind that I withheld lyso for 4 days).

So does this mean we are actually really close to an adequate maintenance dose which could be 2750 mg -3000 mg once we bring down the cortisol via a mini-load?

Doing another mini-load scares me but if you guy’s think that’s the way to go then I will do what needs to be done.
If yes, should the new maintenance dose once he is loaded again be 2750 mg or 3000 mg based on his past response to the Lyso and his weight of 63 lbs?


Any suggestions, thoughts, creative ideas on what to do?

Thanks,
Nathalie

Squirt's Mom
10-21-2009, 01:57 PM
Hi Nathalie,

I was wondering about you and Phillip the other day. Good to hear from you!

To me, it looks like Phillip has lost control of the cortisol and a complete reload is needed. Since the mini-load didn't help and neither have increases in the dosage, this seems to be one of the most logical conclusions. However, there is the possibility that something unrelated to the adrenals is causing the cortisol to rise. Has he been checked lately for any other problems that might have arisen? Like another ultrasound? Cortisol will rise in a natural response to stress of any kind, including physiological so that is something I would want to look into. Of course, my experience with Squirt might have some small bearing. ;):o:p

Hopefully some of the Lyso experts will be along soon to offer a more experienced perspective.

Hugs,
Leslie and the girls

Nathalie
10-21-2009, 06:55 PM
Hi Leslie,

It’s just been very busy between work and the dogs etc. and I have not even had time to visit the board every day – I used to read all the posts religiously.

Please note I have added some additional thoughts/info to my previous …. And yes, a mini-load is what we have to do but I was so hoping we would not have to do it again.

“there is the possibility that something unrelated to the adrenals is causing the cortisol to rise. Has he been checked lately for any other problems that might have arisen?”

As far as we can tell there is nothing else going on. He always gets a ‘look over’ when we go for a stim test. He never had an ultrasound done before.
What I don’t understand is how ‘something else’ can elevate cortisol production when we are eroding the adrenal. Could you please explain this to me? I understand the concept of an Adrenal tumor making it actually harder to erode the adrenals but not any other conditions. :confused:

Thanks,
Nathalie

AlisonandMia
10-21-2009, 07:45 PM
I don't believe that stress will cause elevated cortisol in a treated Cushing's dog - especially one treated with Lysodren. In an untreated dog (Cushing's or not) yes, but not in a treated one as the treatment, by it's nature, forcibly limits cortisol production. This is why a treated Cushing's dog can require a little bit of prednisone if sick, stressed, injured, has surgery etc - it is because the cortisol cannot rise in response to stress so we have to supply the little bit extra artificially. So I don't think any type of stress or illness can be responsible for the rise in his cortisol level.

I do think a mini-load is needed - messing around with increased maintenance doses (that is trying to reload but very slowly) seems to rarely work and often seems to result in a delay in getting things under control and more testing needing to be done. However the fact that this latest increased dose has almost held things stable suggests that that dose will be almost adequate once you've got him reloaded - so you have got some valuable information out of this.

I suspect that given that his cortisol is not yet controlled that he is not getting anything like too much Lysodren and that he may be not absorbing a lot of what he's swallowing. Usually, the only time that a dose sufficient to cause actual side effects unrelated to cortisol level can be given without lowering the cortisol is when an adrenal tumor of some kind is at work. Did you have a high resolution ultrasound of Phillips adrenals at diagnosis, didn't you?

Alison

Nathalie
10-21-2009, 08:18 PM
Hi Alison,


I don't believe that stress will cause elevated cortisol in a treated Cushing's dog - especially one treated with Lysodren. In an untreated dog (Cushing's or not) yes, but not in a treated one as the treatment, by it's nature, forcibly limits cortisol production. This is why a treated Cushing's dog can require a little bit of prednisone if sick, stressed, injured, has surgery etc - it is because the cortisol cannot rise in response to stress so we have to supply the little bit extra artificially. So I don't think any type of stress or illness can be responsible for the rise in his cortisol level.


That was my understanding from what I have learned so far but the vet suggested to do a full blood panel and ultrasound to see if something else could be causing the high cortisol production.
So doing a full blood panel would be a waste of money correct?



I do think a mini-load is needed - messing around with increased maintenance doses (that is trying to reload but very slowly) seems to rarely work and often seems to result in a delay in getting things under control and more testing needing to be done.
Alison

Ok – I will call the vet and let her know I am going to do a mini-load to make sure they have the stim agent in stock. Yesterday they had to get some from the other vet in town ….. what can I say…. :(:(:(



However the fact that this latest increased dose has almost held things stable suggests that that dose will be almost adequate once you've gothim reloaded - so you have got some valuable information out of this.


That’s what I was hoping – thanks for confirming. ;)
So once Phillip is loaded again would you tend to put him on a 2750mg or 3000 mg maintenance dose?



I suspect that given that his cortisol is not yet controlled that he is not getting anything like too much Lysodren and that he may be not absorbing a lot of what he's swallowing. Usually, the only time that a dose sufficient to cause actual side effects unrelated to cortisol level can be given without lowering the cortisol is when an adrenal tumor of some kind is at work. Did you have a high resolution ultrasound of Phillips adrenals at diagnosis, didn't you?


No, I never had an ultrasound done. I don’t think there is anything else I can do to help with absorbtion of the Lyso … I have been crushing his pills and soaking it in Herring Oil for the past month and he always gets a peanut butter sandwich with the Lyso.

Since we did not do an ultrasound, let’s assume he has an adrenal tumor .... are you saying that we could do more harm then good by increasing the dose?
Do you think getting one done is a must at this point?
I would not want to put him through surgery, so how would knowing if he has an adrenal tumor change the treatment?
I don’t know if they use a high resolution ultrasound or not. They quoted me $420 – and it would be performed by and ultrasound specialist (can’t remember the exact name) that travels to differnent offices.

I am starting to feel better already - I have to admit that when I got the test results I felt very discourraged - so thanks. :)
Thanks,
Nathalie

AlisonandMia
10-21-2009, 08:53 PM
Here's a link to a good article on ultrasounds: http://www.dolittler.com/2008/02/9/pet.vet.dog.cat.ultrasound.cost.veterinary.veterin arian.html

From what I can see (courtesy of Google) there is such thing as a high res portable ultrasound - or that's at least what the adverts say.;) From the looks of that article I linked to above, I'd want to know what type of machine this person uses and what their experience and qualifications are and what sort of professional back up (if any) they use. You don't have access to a university vet school do you? They have high resolution machines and good operators.

I've heard of one instance of a real hack with a portable ultrasound who completely misread an ultrasound - and charged about $600.00:eek: - but there are probably really good operators with good machines too.

The other possibility is to do a high dose dex test which is like the LDDS but uses a higher dose of dexamethasone. If the cortisol production is suppressed then it is regarded as positive for PDH but if it doesn't then an adrenal tumor is a strong possibility (but not 100% certain). How valid this test would be when on Lysodren I don't know - your vet may be able to consult with a specialist on this - Dr. Oliver at UTK may be able to help out with that question.

It does sound like he should be absorbing the Lysodren well after it is soaked in herring oil. What exactly is he getting with the Lysodren - including food and how much oil do you use? It occurs to me that I probably used quite a lot of fat/oil with Mia's Lysodren - maybe a lot more than many would. She was on 50mg/kg and had been a very slow loader and very quick to regenerate so maybe I was using quite a high dose (if her serum levels were measured) to control her adrenals - I don't know. She certainly never had any ill effects from it - apart from low cortisol on a couple of occasions. In humans being treated for adrenal tumors, they give really big doses (compared to dogs) and monitor via regular serum measurements and supplement with steroids if necessary. They don't seem to use ACTH stims to guide treatment - but then again the aims of treatment a somewhat different.

I agree with you - doing a full blood panel would be most unlikely to help find the cause of his high cortisol. I think the main thing is to rule out an adrenal tumor if you possibly can. I have heard of a dog (beagle, actually) with confirmed PDH who had been treated with Lysodren for at least a year and who actually developed an active adrenal tumor while on Lysodren! I believe the dog had a successful adrenalectomy and then (once recovered) went back onto the Lysodren for the PDH. So it is possible to have the two diseases at the same time or to have one and then develop the other.

Alison


PS: I'll PM Ken (Buffaloe) about this - he knows a lot more about adrenal tumors and, no doubt, ultrasounds than I do.

Nathalie
10-22-2009, 08:04 AM
We do have a university vet school about 1.5h from here, which is Guelph University. Costs are an issue but I will look into it and see if I can find out how much the cost would be. No point in paying $400 + if I can rely 100% on the person performing it.

“It does sound like he should be absorbing the Lysodren well after it is soaked in herring oil. What exactly is he getting with the Lysodren - including food and how much oil do you use?”

He is getting his regular meal which consists of lean ground beef, mush of greens and some Sunflower Oil (can’t tell exactly how much because I mix in large batches and then freeze in daily portions). I crush the Lyso and put it on ½ slice of white bread and pour approximately 1 teaspoon of Herring Oil on it. With that he gets one slice of white bread with approximately 2 tablespoons of peanut butter and drizzle a little bit of Oil over his food.


“It occurs to me that I probably used quite a lot of fat/oil with Mia's Lysodren - maybe a lot more than many would.”

I have never found any references as to how much oil is actually needed – everything I read just says fat is needed for absorption.
Is there such a thing as a ratio of x-amount of oil to body weight of dog?
How much oil would you use each time I give the Lyso without risking pancreatitis?


“She was on 50mg/kg and had been a very slow loader and very quick to regenerate so maybe I was using quite a high dose (if her serum levels were measured) to control her adrenals - I don't know. She certainly never had any ill effects from it - apart from low cortisol on a couple of occasions.”

For the past month Phillip was on 2500 mg which works out to 87.4/kg and if we put him on 2750 mg that would mean he would be taking 96.85mg/kg (hope I did the math right) – almost double the recommended dose. :eek:
Have you ever heard about a dog being on such a high dose with no ill effects? Would this not be terribly hard on the liver or kidneys?

“I think the main thing is to rule out an adrenal tumor if you possibly can. I have heard of a dog (beagle, actually) with confirmed PDH who had been treated with Lysodren for at least a year and who actually developed an active adrenal tumor while on Lysodren! I believe the dog had a successful adrenalectomy and then (once recovered) went back onto the Lysodren for the PDH. So it is possible to have the two diseases at the same time or to have one and then develop the other.”

So if it turns out that he does have an adrenal tumor, but an adrenalectomy is out of the question, would there be any other benefits aside from knowing this is what is causing his poor response to Lyso?

Thanks,
Nathalie

AlisonandMia
10-22-2009, 09:00 PM
He is getting his regular meal which consists of lean ground beef, mush of greens and some Sunflower Oil (can’t tell exactly how much because I mix in large batches and then freeze in daily portions). I crush the Lyso and put it on ½ slice of white bread and pour approximately 1 teaspoon of Herring Oil on it. With that he gets one slice of white bread with approximately 2 tablespoons of peanut butter and drizzle a little bit of Oil over his food.

I have never found any references as to how much oil is actually needed – everything I read just says fat is needed for absorption.
Is there such a thing as a ratio of x-amount of oil to body weight of dog?
How much oil would you use each time I give the Lyso without risking pancreatitis?


I can tell you what I fed Mia with her Lysodren (do bear in mind she only weighed 9lbs and was on 100mg (1/5 tab) twice a week): 60g kangaroo mince (almost nil fat), 1g fish oil (probably just over one ml) and an approximately 2cm diameter ball of full fat cream cheese (35% fat) into which I poured the crushed Lysodren. That was her dedicated Lysodren meal which she got in the middle of the day away from any other meal. Zac got a little meal of his own too, of course. Both dogs loved Lysodren day!

It does look to me like you are using a pretty comparable amount of oil but I could be way wrong about that - I'll try to look at the math in a while - and you could do and we could compare results (I'm awful with figures:p:o).

I'll see if I can dig out some info on this both from human and canine experiments. I know quantities of fat/oil are mentioned. It may take me a while to track it down again, or find it amongst my bookmarks.:o

It would be great if you could get his serum levels of Lysodren checked. It might be worth asking the vet about whether this can be done. I've never seen it done for a pet dog though - but they have done it in research of course. That sort of checking of drug levels is routinely done for all sorts of other meds though (like anticonvulsants) so it could be a possibility.

I must say the pancreatitis thing worries me especially as Phillip has had a brush with it. Mia never showed any sign either clinically or on blood testing of anything like that. I don't know how much fat is (likely to be) too much fat. Hopefully someone else will. I believe it can depend on the fat too and some fats are definitely worse than others.


For the past month Phillip was on 2500 mg which works out to 87.4/kg and if we put him on 2750 mg that would mean he would be taking 96.85mg/kg (hope I did the math right) – almost double the recommended dose. :eek:
Have you ever heard about a dog being on such a high dose with no ill effects? Would this not be terribly hard on the liver or kidneys?

As I understand it the main effects of Lysodren on the body (apart from the adrenal effects) will be on the central nervous system and this is sometimes seen in humans who are being given much, much larger doses (human adrenal tissue is less vulnerable to Lysodren and they are trying to deal with adrenal cancer rather than just regulate cortisol production). The symptoms seem to be headache, dizziness, fuzzy headedness etc.. There can also be GI symptoms. We have seen a couple of dogs who seemed to get some transient dizziness after their first or second dose during loading but after that it passed (even though the serum concentration would have been rising) and never recurred. It is metabolized by the liver and so does ask something of the liver but is not generally regarded as being hard on the liver the way that NSAIDS are for instance. I don't think it has much impact on the kidneys. There have been some toxicity trials done on rats which I can dig out. Rodents are the favored subject for this because rodent adrenals appear to be totally unaffected so they can give them huge doses and any side effects will be a result of actually toxicity on the whole body rather than the impact on the adrenals. I believe canine adrenals are the most sensitive, which is a good thing.



So if it turns out that he does have an adrenal tumor, but an adrenalectomy is out of the question, would there be any other benefits aside from knowing this is what is causing his poor response to Lyso?

Yes, good question. I guess it depends on how much you need to know - paying for and putting an animal (or person) through a test the results of which are not going to make a significant difference as far as what you are going to do is always questionable, IMO. His LDDS test results don't indicate an adrenal tumor is likely - or was likely at the time of the test (how long ago was it?)

Alison

AlisonandMia
10-22-2009, 09:54 PM
Here's one link:

http://www.ncbi.nlm.nih.gov/pubmed/3685628

It's only an abstract and doesn't mention amounts. It's very possible your vet may have access to the full article and I'd bet the quantities are mentioned in that.

And another abstract: http://www.ncbi.nlm.nih.gov/pubmed/7928549

That one is about treating ADH but shows the variety of doses used - and at least one was on a really huge dose.

This one cites maintenance doses of between 26.8 to 330 mg/kg/week (!!!):

http://www.ncbi.nlm.nih.gov/pubmed/1656032

Don't know if they looked at serum concentrations and whether absorption was being affected by diet etc - but 330mg/kg/week - wow!!

I'll keep looking for those rat studies I mentioned.

Alison

Nathalie
10-22-2009, 10:05 PM
I can tell you what I fed Mia with her Lysodren (do bear in mind she only weighed 9lbs and was on 100mg (1/5 tab) twice a week): 60g kangaroo mince (almost nil fat), 1g fish oil (probably just over one ml) and an approximately 2cm diameter ball of full fat cream cheese (35% fat) into which I poured the crushed Lysodren. That was her dedicated Lysodren meal which she got in the middle of the day away from any other meal. Zac got a little meal of his own too, of course. Both dogs loved Lysodren day!

It does look to me like you are using a pretty comparable amount of oil but I could be way wrong about that - I'll try to look at the math in a while - and you could do and we could compare results (I'm awful with figures:p:o).


Math – yikes – ok, I am going to give this a try … and after checking several converters/Wikki’s, I can’t figure it out … sorry :o
But I found “fish oil supplement or fish oil pill, have 1 gram of fish oil” if this is true then since Phillip is 7 times the size of your Mia it would mean that the equivalent amount would be 7 grams/fish oil pill’s. I am pretty sure he is getting that or even more.



I'll see if I can dig out some info on this both from human and canine experiments. I know quantities of fat/oil are mentioned. It may take me a while to track it down again, or find it amongst my bookmarks.:o


No rush, but it sure would be great to know. I have been wondering about this for quite some time now.



It would be great if you could get his serum levels of Lysodren checked. It might be worth asking the vet about whether this can be done.


Well, I am going to ask – this could be very ‘interesting’ ;):D:rolleyes:



I must say the pancreatitis thing worries me especially as Phillip has had a brush with it. Mia never showed any sign either clinically or on blood testing of anything like that. I don't know how much fat is (likely to be) too much fat. Hopefully someone else will. I believe it can depend on the fat too and some fats are definitely worse than others.


Yes, it is a concern – I don’t want to trigger anything. It’s been almost 1 year since we had a problem while switched from raw to kibble for a few months but everything has been fine ever since I switched him back to raw.
Perhaps the type of fat/oil also makes a difference in absorptions. I was also thinking perhaps there are also other factors to come into play how well a dog/person absorbs a certain drug??



As I understand it the main effects of Lysodren on the body (apart from the adrenal effects) will be on the central nervous system and this is sometimes seen in humans who are being given much, much larger doses (human adrenal tissue is less vulnerable to Lysodren and they are trying to deal with adrenal cancer rather than just regulate cortisol production). The symptoms seem to be headache, dizziness, fuzzy headedness etc.. There can also be GI symptoms. We have seen a couple of dogs who seemed to get some transient dizziness after their first or second dose during loading ……


Well so far, even on such a high dose the only thing I have noticed a bit of stomach upset and I am giving ½ of Pepto prior to the Lyso.




Yes, good question. I guess it depends on how much you need to know, I guess - paying for and putting an animal (or person) through a test the results of which are not going to make a significant difference as far as what you are going to do is always questionable. His LDDS test results don't indicate an adrenal tumor is likely - or was likely at the time of the test (how long ago was it?)


The LDDS was done in March of this year …
Low Dose Dex test results:

Cortisol (0h) 157
Cortisol (2h Dex) 37
Cortisol (6h Dex) 13
Cortisol (8h Dex) 22

Nathalie

PS: just noticed you posted some links - will look at it tomorrow morning - 8 more hours and I have to start work again.
I hope you know that I truly appreciate your help. :)

Nathalie
10-23-2009, 10:00 PM
“It would be great if you could get his serum levels of Lysodren checked. It might be worth asking the vet about whether this can be done.”

I emailed Phillip’s vet and here is her answer:

I have contacted the lab we use and they do not have a test available to check Lysodren levels but are looking into possible sourcing this out to a research lab.

To my question regarding toxicity level she said …

“As for toxicity values there is a large range and really it is a very individual level. A dose that maybe safe and have no negative effects for one dog can be very harmful for another. For Phillip checking full blood including renal and liver values would help us determine if the dose he is on is causing any adverse effects.”

I just don’t understand why she thinks a full blood panel would give good useful information.
We did a panel about 8 mon ago – liver values where very high and since his Cushings has not really been controlled between then and now I am expecting them to be the same or even higher. If the liver values would have gone up we would not know if it is due to the high dose of lyso or because the Cushings is still not controlled.

I don’t know much about the kidneys, but if I recall correctly then75% of the kidney must be compromised before something shows in a blood test?

Is this correct?

She did not say if she has access to PubMed – hopefully she does – I really would like to read the full articles.

Thanks,
Nathalie

PS: Alison, I am impressed that you found these articles on PubMed – I have been there and I find it very hard to get good results when searching for something specific.

AlisonandMia
10-23-2009, 11:33 PM
PS: Alison, I am impressed that you found these articles on PubMed – I have been there and I find it very hard to get good results when searching for something specific.

I've attached a screen shot showing how I find them. Once you've found one vaguely on the right subject that helps you find others.

Nathalie
10-25-2009, 06:46 PM
Phillip’s vet emailed me this morning which is VERY nice considering it’s the weekend ..

She posted to VIN.com for feedback reg. condition/treatment to get feedback from an IM specialist.

She asked if doing a high dose dexamethazone test would be an alternative to the ultrasound to diagnose a possible adrenal tumor and a response is pending.

Feedback from one of the Internal Medicine specialists is that basically if it was not clear if Phillip has an AT she would find out now. Her preference would be the ultrasound possible, hopefully with someone highly skilled in evaluation of the adrenal glands.

"Some dogs with PDH are just like this on the Lysodren---always slipping out of control, but most dogs with AT are like this... "
Her suggestion would be to treat with Trilostane (unless surgery is an option if it turns out to be AT).

Here are my thoughts …
I don’t know, when I look at the numbers we seem to be so close to getting his maintenance dose right.
Yes, his dosage is VERY high but unless we want to try Trilo, not treating will certainly kill him in no time.
Surgery is out of the question, he almost died 4 years ago just from a sedative and there is also the costs involved with it.

We are on day 5 of the mini-load. Based on past mini-loads he should be well loaded but for the life of me I can’t really tell – he is so used by now to operate on a low cortisol level that there is no decrease in appetite. He stops being interested in eating poop below 6 but I can’t tell if he is just below 5 or closer to 1 right now, so I am taking his response to previous mini-loads as a guide.
It’s dinner time now – and I still have not made up my mind if I should give him one more dose. I guess I am just going to see how his appetite is tonight and take it from there.

Nathalie

AlisonandMia
10-25-2009, 08:58 PM
I think you are very close to finding the right dose of Lysodren and I'd definitely hang it with at least for the time being, keeping trilostane as an option if things keep on the way they have been. I always think that whatever treatment has been started should be given a really good go before switching because switching treatments involves allowing symptoms to come back strongly and very likely will result in quite a few stim tests as you get the new treatment on track.

I must say that Phillip's slipping out of control seems to be a bit different from most - in many cases it is because either the dog isn't receiving the dose (either people forgetting or not enough fat in the diet, or a dose that is simply too low being prescribed by a nervous vet) or because proper protocols are not being followed with testing. None of those things seem to be the case here - which is what makes an adrenal tumor seem possible. It is strange because he seemed to load in fairly normal sort of time on 50mg/kg which is usually an indication that around about that dose will be what works. Quick loads often indicate sensitivity to Lysodren and the dog will often need a lower mg/kg to maintain whereas an unusually long load can indicate the opposite. (Mia took nearly a month to load!)

The only other out-of-left-field thing I can think of is that his absorption of dietary fat is impaired in some way. This is should be pretty obvious though with really offensive, nasty poops and probably weight loss as well. I don't know that fat malabsorption affects Lysodren absorption but it makes sense that it would. Pancreatic problems can cause fat malabsorption.

Good luck with the load!

Alison

Nathalie
10-26-2009, 07:42 AM
Thanks for the feedback Alison – I agree, I want to stick with Lyso for now.

Having said that, Phillip is feeling lousy! I am glad I did not give him another dose of Lyso last night. Since last night around midnight he is having stomach problems – he spend most time outside eating grass or just laying on the deck. I tried bringing him in a couple of times but as soon as he was inside he needed to go back outside again.
I don’t know if he has diarreah (no light in the backyard) but I am pretty sure he has been throwing up and he looks and acts like when he had a bout of pancreatitis (so this was never confirmed what it was and I am only guessing) 1 year ago. He defiantly seems to have abdominal pain and he is not eating and being restless. When Phillip stops eating it means he feels really sick. :(
I gave him one pred just in case this is do to the cortisol being too low.
We are going in for a stim test tomorrow. Am I correct that it takes 12h for the pred to leave the system?
Was giving a pred a good idea?
Any ideas on how to make him feel better? I am a bit sleep deprived and can’t think straight right now and have to decide if I need to stay home with him.

I know there is a blood test for pancreatitis - is there any real value in having it confirmed via this test and how would knowing change what we are doing right now?

Nathalie

Harley PoMMom
10-26-2009, 08:33 AM
Hi Nathalie,

So sorry Phillip is feeling yucky...poor boy and poor you...things just can't seem to go smoothly now can they :eek: I found this article about prednisone which Beth asked about too:





Prednisone and prednisolone are considered to be intermediate acting steroids, meaning that a dose lasts about a day or a day and a half. After two weeks or more of use, it is important to taper the dose to an every other day schedule so as to keep the body's own cortisone sources able and healthy.

http://www.marvistavet.com/html/body_prednisone.html

Hi Beth,

Hope this helps...You and Bailey are in my thoughts and prayers.

Love and hugs.
Lori

You and Phillip are in my thoughts and prayers too. I hope Phillip is feeling better soon, I don't know if slippery elm will help him or not.

Love and hugs.
Lori

lulusmom
10-26-2009, 08:43 AM
Hi Nathalie,

You should wait at least 24 hours after the last dose of pred before doing a stim test.

With respect to the pancreatitis issue, I think once you explain everything to your vet, he/she will be the best person to tell you if bloodwork should be done. I believe that bloodwork is the only way to tell if pancreatitis is involved. Thank goodness, I have only had one dog in my lifetime that had a severe case of pancreatitis. Bloodwork was done, her condition was diagnosed, she was hooked up to an IV and off of food and water for two to three days.

Glynda

AlisonandMia
10-26-2009, 08:45 AM
Yes, pred takes 24 hours or so to go out of the system (larger doses seem to take a little longer - must have something to do with half-life). It would probably be best to postpone the stim until he is 24 hours clear of needed in pred. Did he respond to the pred (usually you can see the benefit within the hour). How big are your pred pills?

If the pred doesn't pick him up pretty well and pretty quickly then a trip to the vet would be a good idea. If he can't keep the pill down then he'll need an injection.

Even if you can't do a meaningful stim getting his electrolytes checked would be a good idea though - if for no other reason than that he's been vomiting and possibly has diarrhea.

I don't know much about the pancreatitis tests except that I gather one is a screening test and another one is more specific. If he does have pancreatitis then he'll need to be treated appropriately for that so I think it's necessary to know.

Alison

Harley PoMMom
10-26-2009, 09:27 AM
Hi Nathalie,

When Harley's U/S showed that he had prior bouts of pancreatitis I wanted him tested, his vet and IMS agreed that the cPLI was the test to do to confirm that diagnosis of pancreatitis. Here is an article about it:


Pancreatic lipase immunoreactivity (PLI)

Recently, assays for measurement of pancreatic lipase immunoreactivity in dogs and cats (cPLI and fPLI, respectively) have been developed and validated. As mentioned previously, many different cell types in the body synthesize and secrete lipases. In contrast to catalytic assays for the measurement of lipase activity, use of immunoassays does allow for the specific measurement of lipase originated from the exocrine pancreas.
Serum cPLI was measured in a group of dogs with exocrine pancreatic insufficiency and the median serum cPLI concentration was significantly decreased compared to clinically healthy dogs. In addition, serum cPLI concentration was non-detectable in most of the dogs, indicating that serum cPLI concentration mostly, if not exclusively, originates from the exocrine pancreas. The sensitivity of different minimally-invasive diagnostic tests was compared in dogs with biopsy-proven pancreatitis. The sensitivity of serum TLI concentration was below 35% and that of serum lipase activity was less than 55%. In contrast, the sensitivity for serum cPLI concentration for pancreatitis was above 80%.
In another study of cats with spontaneous pancreatitis serum fPLI concentration was more sensitive and more specific than serum fTLI concentration or abdominal ultrasonography.
These initial data would suggest that serum PLI concentration is highly sensitive and specific for the diagnosis of pancreatitis in dogs and cats. Commercial assays for measurement of cPLI (Spec cPL™) and fPLI (Spec fPL™) are based on the original cPLI and fPLI technology and are available through the GI Lab.


http://www.cvm.tamu.edu/gilab/research/Pancreatitis.shtml

Love and hugs.
Lori

Harley PoMMom
10-26-2009, 09:30 AM
Here's another one from Susy that has alot of really good information in it.


Hi Lori,

You did read the Pancreatitis section in Dogaware.com, right? I've posted the link on so many threads I just can't remember if I did it on yours... but, you're on the forum so much that I'm sure you've read it:p:D;), but here's a link just in case:
http://dogaware.com/wdjpancreatitis.html

-Susy

Love and hugs.
Lori

Nathalie
10-26-2009, 01:24 PM
Thanks Everybody for the information, thoughts and response.

I called the vet office right after I posted and they where able to see us within the hour.

Since his regular vet supposed to be not in today I saw the owner of the clinic and had a good chat. She had seen Phillip about 2 months ago when I brought him along when one of my other dogs had an appointment. She too noticed that physically he does not look well and has deteriated since then.
She tried to feel his liver but because his stomach is quite pot-bellied was not able to get a good feel. His heart rate is slightly elevated but not enough to suggest hypertension and is probably due to the abdominal pain. His temperature is slightly elevated.
His regular stopped by the office and so she took over from there.
We did the following tests:

cPLI
Bile Acids
Blood Panel

She was going to run some of them inhouse but was not able to because there was too much fat in the sample.

He also received a shot of Dexamethason and Cerenaia to calm the stomach. One thing for sure is that they do care – when his vet came in she kicked of her high heels and seat with Phillip on the floor ……

We talked about doing an ultrasound again and the way she looks at it, even so surgery is not an option, if we knew we where dealing with an adreanal tumor then we would at least know when to stop fighting agains something we can’t win. :(:(

At least he does not have raging diarreah, and after throwing up bile 2 times he seemed to be purking up a bit. Right now he is laying curled up in a little dirt hole in the backyard – very, very sad. :(

Tomorrow we will go in for the stim test - it will be 24h after I gave him a pred.
I will keep you posted and let you know tomorrow what the test results are.
Thanks for caring,
Nathalie

Squirt's Mom
10-26-2009, 05:29 PM
Hi Nathalie,

Just want to say that our thoughts and prayers are with you and Phillip for the best possible outcome. Please keep us up to date.

Hugs and belly rubs,
Leslie and the girls

Wylie's Mom
10-26-2009, 05:44 PM
Awwww... poor Phillip, I'm so sorry he's not feeling well:(. And I'm sorry that you are having such a hard time figuring a maintenance dose - it just doesn't make sense to me!!!!

FWIW - The ultrasound can potentially tell much more than if he has an AT... Wylie's ultrasound showed that he had sludge in his gall bladder - which gave a hint of the future gall bladder attack that happened.

My thoughts and prayers are with you too.

-Susy

Harley PoMMom
10-26-2009, 06:00 PM
Nathalie and Phillip,

My heart goes out to you both...and you both are in my thoughts and prayers.

Love and (((hugs)))
Lori

Roxee's Dad
10-26-2009, 08:49 PM
Hi Nathalie,
I am sorry you and Phillip are going thru some rough times. Although I have'nt posted to you much, I have been following every detail, every up and down he has gone thru. You and Phillip are part of our family and I will keep him in my thoughts and prayers. As Leslie said "Hoping for the best possible outcome"

Nathalie
10-27-2009, 05:38 PM
I don’t think I have said this in a while but without you guy’s I would have lost it a long time ago. So thank you for being there and taking the time to do what you do!!! :D
I realize it is quite the commitment and is very time consuming – so thanks again.

Ok – so let me give you an update (this thread starts to read like a bloody book by now) and start with the good news.
Phillip is feeling way better. It’s like he has risen from the dead. His appetite is back, he is still quite weak in the hind end but he already went after a squirrel – go figure. I am not getting payed enough to be put through all this this stress.:D

We did the stim test today and the results will be in tomorrow.
His heart sounds ok and his liver is enlarged – no surprise there.

Pancreatitis has been confirmed ..

Spec cPl: 613 1-200 ug/l
Amylase: 2993 150 – 1350 IU/L
Lipase: 1374 0 – 900 IU/L

Vet said to keep his fat intake down and no more peanut butter sandwiches with the Lyso, just some Herring Oil.
This is not helping with absorption of the Lyso and she still has not received any feedback from the internal med adviser on her online board as to recommended amount of oil and type and unfortunately she does not have access to PupMed even so she registered.
I would not be surprised if they simple don’t know.

ALP went up from 2475 to 4291 (normal range: 24 – 141)
Now get this, his ALT went down to within normal range of 51 from 165 (normal range: 5 – 95) . So, he has got a pretty healthy liver that is enlarged that is working like crazy.
Perhaps giving him Milk Thistle 12 drops 2x per day really helped.

I know that such a high number in ALP could indicate cancer. Vet said yes, especially bone carcinoma.
I don’t even know what to say about this ….

WBC is slightly elevated and Neutrophilis is 86.3 – per vet this could indicate some type of infection. We might be able to bring the number down with some antibiotic but we don’t want to put more into him as is necessary.

I am going to start him on 2750 mg of Lyso per week as his new maintenance dose pending stim test results.

Looking back over the last couple of days I think what happened was a combination of his cortisol going to low at the end of the mini-load in conjunction of needing more due to the pancreas flaring up which caused him to crash.

So this new maintenance dose better be it – I am not going to do any more loading around her – I am not kidding you.

Also, we briefly talked about what to do if the new dose does not hold the cortisol in check, in which case I will have to do the ultrasound. I found out the person coming to the clinic to do ultrasounds is a Vet something or other specialist (can’t remember the title) but she still needs to confirm what type of machine he uses. I mean, we really can’t go on like this, increasing the dose every month and doing these tests …
But, I am feeling positive today – and miracles do happen at times – we are due for a little one I think.

Almost forgot, while I was there IDEXX lab called back and confirmed that there is no test to confirm that therapeutic Lyso leves have been reached because every dog does require different dosages.

I think that covers it all.
Thanks again,
Nathalie

Harley PoMMom
10-27-2009, 07:46 PM
Hi Nathalie,

I am so happy Phillip is feeling better, and you are so right, YOU are not getting paid enough!! :eek::p:D

Now...oh dear, remember Harley was tested for pancreatitis too, and his was confirmed also with the PLI, anyways, I wanted to run another UTK full adrenal panel on him and Dr Oliver and Harley's IMS both said that pancreatitis can skew ACTH stim results, so I just wanted to remind you that Phillip's stim results might not be "true." I'm sorry for this, I should of said something before but...no buts...I'm sorry.

As for the ALP, I really believe this is so high bc of the cushings still not being controlled, and now with the pancreatitis. Harley's jumped from 416 to 1289 in 4 months.

That ALT is GREAT...YAAA!!! :D:):D:)

And yes I sure do agree, you are due for a miracle...overdue infact. So I am sending my most positive thoughts, healing prayers, and optimistic vibes your way.

Love and hugs.
Lori

Nathalie
10-27-2009, 08:06 PM
Now...oh dear, remember Harley was tested for pancreatitis too, and his was confirmed also with the PLI, anyways, I wanted to run another UTK full adrenal panel on him and Dr Oliver and Harley's IMS both said that pancreatitis can skew ACTH stim results, so I just wanted to remind you that Phillip's stim results might not be "true." I'm sorry for this, I should of said something before but...no buts...I'm sorry.

Lori, you don’t have to be sorry about anything! Darn, the vet should have known about this, even the specialist at IDEXX did not say anything and he knew we just ran the blood work for pancreatitis and knew the result and I overheard the vet telling him that we are doing a stim right this min.

So, does this mean the results come back higher then they actually are or lower? Now what?
On the other hand, how could we have avoided doing a stim after the end of a mini-load and him seeming to crash?




As for the ALP, I really believe this is so high bc of the cushings still not being controlled, and now with the pancreatitis. Harley's jumped from 416 to 1289 in 4 months.


So do you think it is possible for the ALP to increase to 4291 and him not having cancer?

The ALT being right smack in the middle of normal took me by surprised – I would have never thought this being possible – Long Live the Milk Thistel!:p

Nathalie

AlisonandMia
10-27-2009, 08:17 PM
The stim shouldn't be affected by the pancreatitis - it would be if it was a diagnositic stim but because it's a treatment stim it should give an accurate reading as to the cortisol-producing capacity of his adrenals - as long as the pred is out of his system. If the injection he was given was dexamethasone then that won't skew the test (by reading as cortisol) but if it was anything else (like cortisone) then it likely will unless enough time has been allowed for it work out for his system.

I hope his problems with pancreatitis and fat is not going to make treatment with Lysodren untenable - I can imagine that that could be the case with some dogs although I've never seen it happen. I mentioned it before, but you may have missed it, but I wonder if pancreatitis-related fat malabsorption could have something to with his "Lysodren resistance". Fat malabsorption causes disgusting, fatty poops so you will probably have noticed something if that is the case. Could be worth discussing this possibility with the vet.

Alison

Harley PoMMom
10-27-2009, 09:12 PM
Nathalie,

When I was contemplating on whether to put Harley on a maintenance dose of Lysodren, I decided to stim him knowing that his stim could be skewed. He stimmed within the normal ranges and his vet and IMS still wanted to put him on the maint. dose, then I reminded them both about how pancreatitis can skew stim results, so Harley's #'s could actually be lower than what the results were saying ( his pre was 3.2ug/dl & and his post was 12 ug/dl) and I reminded them also that Dr Oliver even said that this is true, I emailed him and asked him. They both agreed to no Lysodren for now.

I really don't think you could of avoided doing your stim today tho, just keep in mind that your numbers might be alittle off...please, maybe, ask your vet to check into this.


So do you think it is possible for the ALP to increase to 4291 and him not having cancer?I think it is possible with our poor cushingnoid pups, especially when they have multiple issues going on, tho an ultrasound would show more.

This is quoted from Broadway Veterinary Hospital/Laboratory Assessment Descriptions:


The Alkaline Phosphatase is profoundly elevated. This is a liver enzyme that is released when there is any type of inflammation in the liver tissues. The two most likely conditions to cause such a profound elevation are an obstruction of the bile flow from the liver (as with a gall bladder stone, pancreatitis, or tumor) or from a high level of systemic steroids (glucocorticoids), either from overdosing this medication or from a hormonal disorder called Cushing’s Disease.
http://www.broadwayvh.com/site/view/83223_AssessmentDescriptions.pml

Love and hugs.
Lori

Nathalie
10-28-2009, 06:56 PM
I mentioned it before, but you may have missed it, but I wonder if pancreatitis-related fat malabsorption could have something to with his "Lysodren resistance". Fat malabsorption causes disgusting, fatty poops so you will probably have noticed something if that is the case. Could be worth discussing this possibility with the vet.


Nope, didn’t miss it – I read every word you write :D - I have it in the back of my head but never brought it up at the vets because his poops are usually always perfect. But thanks for mentioning it again.

Lori – I am going with the explanation that the high ALP is due to pancreatitis and cushings and totally ignore the cancer bit. At the end of the day there is nothing we can do about it anyways.

I have yesterdays stim test results and no wonder he crashed!

Pre: 0.36
Post: 3.2

I mentioned to the vet the possibility that results are not a 100% accurate – she said not to worry about it because the post is well within range and this new maintenance dose should keep him steady.
I am not bringing out the bubbly yet but I am being optimistic.

What does not quite make sense to me how is pre can be so low and his post smack in the middle. I would have expected a post that is much lower based on all the past stim tests we did.

The plan is to let his resting cortisol rise a bit – keeping in mind that his adreanal regenerate quickly. I am planning to give him is first dose of Lyso on Friday which will be 5 full days after his last loading dose. He is still a bit weak and not very enthusiastic when we walked today. Appetite is back to normal.
His new maintenance dose will be 2750mg.



When I was contemplating on whether to put Harley on a maintenance dose of Lysodren, I decided to stim him knowing that his stim could be skewed. He stimmed within the normal ranges and his vet and IMS still wanted to put him on the maint. dose, then I reminded them both about how pancreatitis can skew stim results, so Harley's #'s could actually be lower than what the results were saying ( his pre was 3.2ug/dl & and his post was 12 ug/dl) and I reminded them also that Dr Oliver even said that this is true, I emailed him and asked him. They both agreed to no Lysodren for now.

Perhaps what they mean by pancreatitis can skew a stim test is that it can somehow corrupt (can’t think of a better word right now) the result eg. something is interfering when they run the test and not the pancreatitis actually truly increasing cortisol output?

Not that it really matters in the end but now I am curious because I can’t wrap my mind around how for eg. pancreatitis could cause more circulating cortisol when there is only a certain amount that an adrenal that has been corroded by Lysodren can produce.

Lori would you know exactly how they believe it skews the result?

Alison, I am going to try my luck on PupMed and see what I can find out and try your search pointers.

I could ask Phillips vet but I think we have to give them a little bit of a break for a couple of weeks. ;)

Nathalie

Harley PoMMom
11-02-2009, 09:55 AM
Hi Nathalie,



Lori – I am going with the explanation that the high ALP is due to pancreatitis and cushings and totally ignore the cancer bit. At the end of the day there is nothing we can do about it anyways.

I really do believe once you get both of these under control then that ALP will come down.

I have yesterdays stim test results and no wonder he crashed!

Pre: 0.36
Post: 3.2

I mentioned to the vet the possibility that results are not a 100% accurate – she said not to worry about it because the post is well within range and this new maintenance dose should keep him steady.
I am not bringing out the bubbly yet but I am being optimistic.

What does not quite make sense to me how is pre can be so low and his post smack in the middle. I would have expected a post that is much lower based on all the past stim tests we did.

The plan is to let his resting cortisol rise a bit – keeping in mind that his adreanal regenerate quickly. I am planning to give him is first dose of Lyso on Friday which will be 5 full days after his last loading dose. He is still a bit weak and not very enthusiastic when we walked today. Appetite is back to normal.
His new maintenance dose will be 2750mg.

Perhaps what they mean by pancreatitis can skew a stim test is that it can somehow corrupt (can’t think of a better word right now) the result eg. something is interfering when they run the test and not the pancreatitis actually truly increasing cortisol output?

Not that it really matters in the end but now I am curious because I can’t wrap my mind around how for eg. pancreatitis could cause more circulating cortisol when there is only a certain amount that an adrenal that has been corroded by Lysodren can produce.

Lori would you know exactly how they believe it skews the result?

I really don't know but I do intend to find out. My thinking is: pancreatitis causes stress to the pup and stress makes the cortisol rise thus interfering with the ACTH stimulation assay and then, now this just my theory here, I know Harley every now and then has some discomfort from either his pancreatitis or arthritis so I give him his Tramadol and then he is very relaxed, not stoned or anything but relaxed, so I'm thinking :eek: If I would ever of gotten him stimmed when he was stressed from pain ~ stim higher and If I would of gotten him stimmed when he was on the Tramadol ~ maybe stim lower bc of stress being way lower? What do you think of my theory...anyone else have an opinion or theory? :)


Alison, I am going to try my luck on PupMed and see what I can find out and try your search pointers.

I could ask Phillips vet but I think we have to give them a little bit of a break for a couple of weeks. ;)

Nathalie

Best of luck to you and I hope your new maintenace dose works.

Love and hugs.
Lori

Nathalie
12-06-2009, 10:16 AM
Another month another stim test …

Good news, for the first time Phillip did not go above 5 after being on a maintenance dose (2750 mg).
His most recent pre was 1.2 and his post was 2.8.

I am seeing a lot of hind leg tremors and shaking and I think he would feel better with his cortisol around 4. I was hoping that by now he would have re-gained some of the muscle mass he has lost but no such luck.

His vet seems to think this is as good as it gets and that age is kicking in. She suggested to up his Soloxine from 0.4 to 0.5 to maybe help with the hind end weakness.
With his last stim test I also did a FT4 which was 2.8 which is already above the Optimal Geriatric Therapeutic Level of 0.70 - 2.00 ng/dL
I just know his hind end weakness is a result of Cushings (perhaps the high dose of Lyso may also play a factor in this) so I emailed Jean and she confirmed to not increase his Soloxine considering his age and his good therapeutic response to the Soloxine.

I am still not sure about the accuracy of the stim test results after the last mini-load Pre: 0.36 Post: 3.2. The actual lab report states >10 mnl for pre, which I think means too low to measure. His vet thinks the results may have been skewed due to Pancreatitis at the time.

So, I still can’t be certain that 2750 mg is an adequate maintenance dose. As I mentioned before I would like his post number to get a bit closer to 5 as he just feels better at the higher end – where he is at right now he is also quite itchy. Vet suggested to do another stim test in 6 weeks but I think I will do another one in 4 weeks – I just don’t want to take the risk in him getting any lower or too high again.

His left elbow has healed completely but the right elbow which has been chronically inflamed but no puffiness since we took the DogLeggs off had this little bubble like growth which is getting bigger now. This could potentially turn into a real problem if it keeps on growing – vet is not sure if it is a growth or a response of the body to pressure – as he is not a candidate for surgery.

Thanks,
Nathalie

Harley PoMMom
12-06-2009, 07:29 PM
Hi Nathalie,

It is so good to hear from you, I was starting to get worried. :)

Those are great numbers...but they are numbers, if Phillip is not well on those numbers...as the saying goes...You know Phillip best.

As far as the muscle wasting I have Harley on L-Glutamine for that, and it is also got for the GI tract.

Here is excerpt from an article about L-Glutamine:


Role of Glutamine in Health and Disease.

Colorado State University
Elisa Mazzaferro, DVM, MS
Timothy Hackett, DVM, MS
Wayne Wingfield DVM, MS
Greg Ogilvie, DVM
Martin Fettman, DVM, PhD


Alterations in Glutamine Metabolism.

In critical illness, glutamine metabolism is altered in tissue. Profound changes in amino acid distribution occur as plasma and intracellular glutamine concentrations fall. The release of glucocorticoids and inflammatory cytokines results in a unidirectional flux of glutamine from muscle and lung in excess of glutamine production. The release of glucocounterregulatory hormones during stress and disease stimulates glutamine uptake and use by the GI mucosa. The accelerated export of glutamine in excess of its synthesis depletes muscle glutamine concentrations by 30% or more, causing protein catabolism and muscle wasting.

http://www.scribd.com/doc/23752319/Role-of-Glutamine-in-Health-and-Disease

Harley is on 500mg 2X week, and yes it is per his vets approval. I get his L-Glutamine from Monica Segal's website. If you're interested just let me know.

Love and hugs,
Lori

Nathalie
12-06-2009, 08:46 PM
Hi Lori,

My furnace is on its last leg and with the cost of replacing it and Phillip’s medical expenses I have been going through a few very stressful weeks – but things are sorted out now – and I am no longer worried where the money supposed to come from for Phillip’s treatment. Hopefully they will be able to install the new furnace next week so we don’t have to rely on the space heater as it is starting to get colder here in Canada.

My goal is to let the number come up a bit to where the itching stops and to help with the inflammation of his right elbow. But since it took so long to get to this point I don’t won’t to mess around with the dosage or skip a dose in order to get a true reading with the next stim test.

Thanks for the info on L-Glutamine – I am defiantly interested. How did you determine the weekly dosage? What positive changes did you see in Harley and how long did it take for it to kick-in?
Is L-Glutamine also available in Health Food stores or would it be best to order it from Monica?

I am just tired of some people/vets dismissing things because the dog is a certain age – such as his hind legs muscle wasting. I just know this is not part of his normal aging process so let’s try to do something about it if we can. It sure would be a shame if he would loose the use of his hind legs after coming this far.

Thanks,
Nathalie

AlisonandMia
12-06-2009, 09:12 PM
I think it would be worth just keeping things as you have them now and then re-stimming at 4 weeks to check that this maintenance dose is holding things stable. Once you've ascertained that (and fingers crossed that the numbers are being held stable) then you could skip a dose or two to let his numbers rise slightly and then back onto the present dose.

It does look like his numbers could have come down a bit since loading though so it's possible that this maintenance dose is just a shade high - another reason to do that stim at 4 weeks rather than 6, I think.

I've read that creatine is good for preventing muscle wasting in humans on steroid medication. In humans it is usually supplemented but in dogs this shouldn't be necessary (and could even be hazardous). I believe that raw meat (particularly red meat) is the very best source of creatine (it can be denatured somewhat by cooking) so Phillip is probably getting enough creatine. With the older ones it can take a while for them to recover their fitness.

It amazes me too that older dogs are written off because "he's only going to live another couple of years" - but that's the equivalent of 12 - 15 years for a human and a pretty decent percentage of a dog's lifespan. My mother is 75 and I don't think she'd like to be written off at this stage of her life!

Alison

Nathalie
12-06-2009, 09:34 PM
I think it would be worth just keeping things as you have them now and then re-stimming at 4 weeks to check that this maintenance dose is holding things stable. Once you've ascertained that (and fingers crossed that the numbers are being held stable) then you could skip a dose or two to let his numbers rise slightly and then back onto the present dose.

It does look like his numbers could have come down a bit since loading though so it's possible that this maintenance dose is just a shade high - another reason to do that stim at 4 weeks rather than 6, I think.

I totally agree – the vet suggested to wait 6 weeks before another stim but I am going to take him in in 4 weeks. That way I will know exactly what this currently dose does.



I've read that creatine is good for preventing muscle wasting in humans on steroid medication. In humans it is usually supplemented but in dogs this shouldn't be necessary (and could even be hazardous). I believe that raw meat (particularly red meat) is the very best source of creatine (it can be denatured somewhat by cooking) so Phillip is probably getting enough creatine. With the older ones it can take a while for them to recover their fitness.

After his pancreatitis episode I cooked for him for a couple of weeks but since then he is back on the same raw diet as before and seems do be doing well on it – perfect poops for the most part.



It amazes me too that older dogs are written off because "he's only going to live another couple of years" - but that's the equivalent of 12 - 15 years for a human and a pretty decent percentage of a dog's lifespan. My mother is 75 and I don't think she'd like to be written off at this stage of her life!


You are so right. I think many older dogs suffer unnecessarily because they are written off when they hit a certain age. The same goes for people. This type of attitude bothers me to no end – I guess I just have to learn to ignore such comments.

Thanks,
Nathalie

Harley PoMMom
12-06-2009, 09:36 PM
Hi Lori,

Thanks for the info on L-Glutamine – I am defiantly interested. How did you determine the weekly dosage? What positive changes did you see in Harley and how long did it take for it to kick-in?
Is L-Glutamine also available in Health Food stores or would it be best to order it from Monica?


Thanks,
Nathalie

Hi Nathalie,

The dosage was determined by Monica and my vet, on the label of the bottle of L-Glutamine I have it says "1 capsule per 30 pounds of bodyweight or as directed by a veterinarian." My vet sells L-Glutamine also but I explained to Dr Owings that I want to buy and give Harley Monica's supplements because she is formulating his diet and Monica knows what is in her own supplements...anyways the
L-Glutamine from Monica's site cost me $11.99 + $7.99 parcel bc she is in Canada. This is for 100 capsules @ 500mg.

It did not take long for me to see changes in Harley but he did not have that much muscle wasting. There in the beginning of Apr. he couldn't jump on the couch without my help. He started taking the L-Glutamine on 9/21 and in a couple weeks he was jumping on the couch himself. Also when we would play frisbee, before the L-Glutamine, his back legs would shake after just a couple of tosses, I never throw the frisbee in the air for him to jump for it rather I just sorta toss it so it hits the ground and he runs and fetches it and brings it back. Now, that shakiness is gone in his rear legs.

I think you can buy it in a health store, not sure, your vet probably sells it tho, like I said mine did, and I would ask your vet about using it too.

Here is a link to Monica's site if you're interested.


L-Glutamine 500 mg

Description:
L-Glutamine is a component of cells that are plentiful in the epithelial lining of the gastrointestinal tract. L-Glutamine can help conserve muscle glycogen stores, support the health of nerve cells, and cross the blood-brain barrier where the brain uses it for fuel.

Recommendations:
Give one capsule per 30 pounds of bodyweight, or as directed by your veterinarian.

Each capsule contains 500 mg L-Glutamine. Does not contain preservatives, dilutents, or artificial additives and is not derived from animal sources.

http://www.monicasegal.com/catalog/product.php?products_id=338

Hope this helps.

Love and hugs,
Lori

jrepac
12-06-2009, 11:05 PM
L-Glutamine can be found in GNC or other health food stores, Vitamin Shop, Puritan's Pride and other online shops as well. It may be hard to find the 500mg dose, as it usually comes in bigger doses. Body builders take it, that's why. It is recommended to counter the muscle wasting, as you can see.

you will find it in caps or tabs; I prefer the caps when I can find them. Since it is tasteless, you can mix it w/other stuff.

I'm doing 500mg once per day for my 22lb Aussie Terrier.

She's got a bit of muscle weakness in the hind legs....it does vary tho, so hard to know from day to day.

I figure it can only help.

Jeff

Nathalie
12-14-2009, 01:03 PM
Thanks for the info Lori and Jeff. :)

I gave Phillip his first dose of 1000 mg (he weights 63 lbs).
Is he supposted to get this daily? I 'think' I read somewhere to give it 3x per week??
Also, is it better to give with food or away from food?

Thanks,
Nathalie

Harley PoMMom
12-14-2009, 02:14 PM
It is best to give L-Glutamine at least one hour before any meal ( empty tummy is best). I believe 3X a week is sufficient. Let me know if you see any changes, and the best of luck...fingers, toes and everything I can find crossed that this helps Phillip.

Love and hugs,
Lori

Nathalie
12-30-2009, 05:49 PM
We had another stim test done yesterday and Phillip's current maintenance dose of 2750 mg is still not adequate – since December 2nd the cortisol has risen by almost a full point.:(

Here are his last 3 test results:

October 28:
Pre: < 0.36
Post: 3.2 (after mini load, had pancreatitis)

December 2:
Pre: 1.3
Post:2.97

December 29:
Pre: 1.63
Post:3.87

Notice the decrease of the post value between October and December 2 and the increase between December 2 and December 29 while being on same Maintenance dose of 2750 mg ….
If pancreatitis skews stim tests results for a dog that is being treated with Lysodren that would explain why it appears we have a decrease and then an increase of his post numbers.
BUT, I asked the owner of the clinic and she called IDEXX Lab and according to them pancreatitis does not affect stim test results if the dog is being treated with Lysodren.

So, our best guess to explain these numbers is that Phillip most likely has an adrenal tumor and it is growing.

So we have to increase his maintenance dose to 3000 mg (104.3 mg/kg)

This is all so discouraging to say the least. What if 3000mg still isn’t enough??? Then there is the worry about toxicity. I don’t want to poison him while trying to keep him asymptomatic.:eek:
Even so his ALT has improved since the beginning of the year and is now within normal range, the ALP has doubled to over 4000 since then. The vet said that we now have to really closely monitor him for signs of toxicity and recommended we do a Full Chem Panel, Acid/Bile with his yet another stim test in 4 weeks – yikes.

We did have a talk about ‘quality of life’ and she agreed with me that he is looking much better compared to 2 month ago and not uncomfortable in any way – she thought back then that he would not make it much longer. She mentioned also that none of her other clients monitors their cushings dog as diligently as I do and she can’t make them come in for monitoring unless the dog becomes symptomatic again. This made me feel good – not that it has helped a heck of a lot.

Right now my gut feeling tells me we are fighting a battle we can’t win in the long run. I mean we can’t possibly keep on increasing his dose and doing test after test after test.

If the culprit indeed is a growing adrenal tumor then it would make sense to supplement with something that has, at least some good anecdotal evidence of stunting or shrinking tumors. A friend of mine mentioned Maitake D-Fraction (http://www.maitake.com/whats_new.php?news_id=8) but I have not done any research on it myself.
Boosting his immune system is also something I am looking into. Now we really could use a good integrative vet – there is just too much info out there.
Are any of you seeing an integrative vet and would you mind sharing what you use to support your dogs immune system or anything else you found beneficial?

Thanks for reading yet again another long winded post of mine :o
Nathalie

Franklin'sMum
12-30-2009, 09:21 PM
Hi Nathalie,

I'm sorry Phillip is having issues related to controlling his cortisol and the possibility of an adrenal tumor :(.
The mushroom thing I've come across before. Apparently there are 6 types of mushrooms with anti-cancer properties, but I don't know if all of them are suitable for pups. "Maitake, Reishi, and Shitake" are 3 types of "medicinal mushrooms" with "anti-tumor, anti-viral, anti-inflammatory and immune enhancing" properties. I don't know where that info is from originally, just found the scrap of paper where I wrote it. Great to know that Maitake-D is specifically for pups, though. I give Franklin 1/4 teaspoon of spirulina 2x a day (usually).
About Phillip's raw diet...do you supplement with anything in particular? (Can't remember your whole history, sorry). There's a food called "Life's Abundance", formulated by Dr Jane Bicks. (Not available in Oz) www.healthypet.net will give you more info on it, but she claims it has anti-tumor potential.
Hope this helps,

Jane and Franklin xx
________
LovelyWendie99 (http://www.lovelywendie99.com/)

Squirt's Mom
12-31-2009, 11:45 AM
Hi Nathalie,

Even tho Phillip's numbers seem to be creeping up, those are still GREAT numbers for a Lyso pup! How is he anecdotally? Any signs coming back? Remember to treat the dog, not the numbers; if Phillip seems to be feeling good, then don't let the numbers worry you too much. I realize you don't want to have to do another load nor do you want to keep giving him higher and higher doses, but rely on his behavior to say he needs an increase, not solely on the the numbers.

How long has it been since he had an ultrasound? That would be the next test I would want done, in fact I would be insisting on it. The unknown drives me batty so I would have to know what is going on inside. It could be that he has something similar to what Squirt went through - a non-adrenal cause for the cortisol levels, or at least contributing to the cortisol rise. It would be worth all the difficulty to get that U/S done asap to me....JMHO. ;)

What little info was available on the Maitke-D sounds pretty encouraging for cancer patients. I was reading last nite and came across something that retards blood vessel growth in tumors which will starve the growth but for the life of me I can't remember what it was - or which text it was in. :rolleyes: But I will look and let you know when I find it again. I have been using Astragalus for over a year now and have had no problems with it at all. It is an adaptogen, an agent that protects the body from stress. I do have some links to give you on Astragalus. I prefer it as a tincture, but whatever works best for you and Phillip.

Hugs,
Leslie and the girls - always

Astragalus info:

http://nccam.nih.gov/health/astragalus/

http://www.umm.edu/altmed/articles/astragalus-000223.htm

Nathalie
12-31-2009, 03:32 PM
Hi Nathalie,
I give Franklin 1/4 teaspoon of spirulina 2x a day (usually).
About Phillip's raw diet...do you supplement with anything in particular? (Can't remember your whole history, sorry). There's a food called "Life's Abundance", formulated by Dr Jane Bicks. (Not available in Oz) www.healthypet.net will give you more info on it, but she claims it has anti-tumor potential.


Hi Jane,
I am feeding Urban Wolf (http://www.urbanwolf.cc/), have been for close to 7 years now. Everybody here is doing well on it and as long as I keep the oil low, Phillip’s poops are perfect so that’s why I rather would start supplementing instead of switching food. When he used to be under the care of an integrative vet he used to be on a spirulina product, bloodroot, burdock and a whole bunch of other stuff I can’t remember. That’s the vet who under and misdiagnosed him and once I had hypothyroid and cushing’s confirmed I stopped everything because I wanted to start over and once regulated on Lyso to start adding. Now he is only getting a moderate amount of Herring Oil, used to give Flax but I read somewhere (might have been on here) that Flax Oil can exasperate pancreatitis, L-Glutamine 3000mg per week and Milk Thistle.


Even tho Phillip's numbers seem to be creeping up, those are still GREAT numbers for a Lyso pup! How is he anecdotally? Any signs coming back? Remember to treat the dog, not the numbers; if Phillip seems to be feeling good, then don't let the numbers worry you too much. I realize you don't want to have to do another load nor do you want to keep giving him higher and higher doses, but rely on his behavior to say he needs an increase, not solely on the the numbers.


Hi Leslie,
The only symptom that is back is that he is more hungry and therefore tries to eat poop again. Initially this had stopped completely when we started him on Lyso but has been an issue for the past few months even when the cortisol was lower then it is now. Hence, I am thinking that there is some other condition/imbalance causing this and not necessarily cushings related anymore. I agree, these numbers are great and he is doing considerably ok. BUT if the current dose is allowing the cortisol to rise and I would not increase the dose, then potentially the cortisol could rise at the same level it has for the past month which means I would be forced to do a mini-load in no less then 3 months. So my worry is not the numbers but the potential steady increase of cortisol over a relative short time. Even so I am concerned about ‘silent’ damage with a post of over 5 I would be more then ok with a post of 6.5 as long I knew the maintenance dose was adequate. After doing 10 stim tests in 7 months I pretty much know what to see at different levels and anything over 6.5 he get’s VERY hungry again, driven to look for something to inhale all the time which is not way to live either. I hear you when you say ‘don’t forget to treat the dog …’



How long has it been since he had an ultrasound? That would be the next test I would want done, in fact I would be insisting on it. The unknown drives me batty so I would have to know what is going on inside. It could be that he has something similar to what Squirt went through - a non-adrenal cause for the cortisol levels, or at least contributing to the cortisol rise. It would be worth all the difficulty to get that U/S done asap to me....JMHO. ;)


I never had an U/S done because of financial reasons. Yes, it would be nice to know if he indeed has an adrenal tumor but since he is no candidate for surgery, it is my understanding that knowing would not make a difference in his cushings treatment. His vet has been pushing an U/S before as it seems to be her opinion that it would make the decision easier to stop treatment and the financial burden on me. As you know there is nothing bloody easy about this! It would be a different story altogether if he was suffering, which I am certain he is not. I just cannot accept yet that the only treatment available to us is not working for my Phillip.
What other condition caused Squirts cortisol levels to rise?
The way I understand it, a dog treated with Lyso has only a certain amount of cortisol available and therefore can not produce extra cortisol even when needed eg. stress or illness.

Thanks for the info on Astragalus – I certainly will look into it.

Nathalie

Squirt's Mom
12-31-2009, 04:51 PM
Hi Nathalie,

I have found what I was thinking of along with some more info and will PM it to you in a bit.

First, understand that Squirt was never on Lyso or Trilo. Her vet said we caught the disease early as her signs were few and those were mild. Squirt's initial treatment was Anipryl. Seven months after being diagnosed with PDH, a splenic tumor was discovered during an abdominal ultrasound. Her adrenals were fine, a bit enlarged but nothing dramatic and no tumor(s) there - just on the spleen. Once the splenic tumor was out, her cortisol levels returned to normal and have remained that way since this surgery in 9/08. Soooo, her docs say the initial diagnosis of PDH is "highly questionable." :cool::):cool:

This is why the expense, the hassle, the stress is all worth having this test done. Non-adrenal conditions - problems that have nothing to do with the adrenal glands which play a major, integrative role in Cushing's - can cause cortisol levels to rise and be read on Cushing's specific tests as positive. Squirt had the LDDS, the HDDS, 2 ultrasounds, an ACTH and the UTK panel done - all indicated PDH. I refused to start Lyso or Trilo until, 1.) Squirt developed more signs; 2.) Squirt's current signs became stronger; 3.) Everything else had been ruled out beyond doubt; 4.) I educated myself a bit. I am extremely glad I took that perspective and approach with Squirt! She is Atypical, but I no longer think she has true hyperadrenocortisim (Cushing's) at this time. It could develop any day, but for now that tumor was the cause of all Squirt's positive Cushing's specific tests. ;) Of course, she is a cush odd-ball! :rolleyes::p

This is also why it terrifies me to see folks starting their babies on Trilo or Lyso based on one positive test. :eek: And, why I always urge folks to have an ultrasound done, at least one. IMHO, the ultrasound and the UTK panel are the most valuable tests you can have done. If funds are limited, as they are for me and most others here, spend your money on those two tests. They will tell more than any other tests or combination of tests.

Ok...gotta run for now but will be back later to check in and try to get that PM off to you. :o

Hugs,
Leslie and the girls - always

Harley PoMMom
12-31-2009, 05:03 PM
Hi Nathalie,

Oh my, poor you and Phillip...this rollercoaster ride they have you on, are they ever going to let you get off and relax!! :eek::(:)

According to Dr Feldman about why dogs are not responding to Lysodren:
Possible explainations for resistance are the dog is not receiving or absorbing the drug (it should be administered after meals); the dog has an adrenocortical tumor; the diagnosis is incorrect; and the dog may have a resistant form of PDH.

http://www.io.com/~lolawson/cushings/articles/feldman5.pdf

Now I'm probably grabbing at straws here, so bear with me. If Phillip would have EPI (Exocrine Pancreatic Insufficiency), which one of the symptoms is a dog eating his poop bc he is very hungry, his Lysodren would not be absorbed bc his food remains undigested and unabsorbed. Now not all dogs with EPI carry the same symptoms, some have more severe and some less severe, so maybe in Phillip's case, if he would have EPI he's just not showing all of the typical signs?? I guess what I'm thinking here is that usually his Lysodren does actually get absorbed but there are days that it doesn't and maybe the EPI could be an explanation for that??

Here's a really good short article on EPI.

http://www.epi4dogs.com/

Love and hugs,
Lori

littleone1
12-31-2009, 05:45 PM
Hi Nathalie,

I'm so sorry that Phillip is having problems. I hope everything will be able to be resolved very soon.

Terri

Nathalie
12-31-2009, 07:35 PM
First, understand that Squirt was never on Lyso or Trilo. Her vet said we caught the disease early as her signs were few and those were mild. Squirt's initial treatment was Anipryl. Seven months after being diagnosed with PDH, a splenic tumor was discovered during an abdominal ultrasound. Her adrenals were fine, a bit enlarged but nothing dramatic and no tumor(s) there - just on the spleen. Once the splenic tumor was out, her cortisol levels returned to normal and have remained that way since this surgery in 9/08. Soooo, her docs say the initial diagnosis of PDH is "highly questionable." :cool::):cool:


Hi Leslie,
Right – now I remember Squirts background. When I responded to your post I for some reason thought that Squirt was on Lyso. :o I totally understand that a dog that is not being treated for cushings can have elevated cortisol levels due to conditions other then cushings. Having gone through all of this so far I too would now choose to do an U/S prior to starting treatment. If I remember correctly, there was no mention of an U/S prior to starting the Lyso as the LDDS was indicative of PDH – never mind a UTK panel.

Nathalie

Nathalie
12-31-2009, 08:53 PM
Oh my, poor you and Phillip...this rollercoaster ride they have you on, are they ever going to let you get off and relax!! :eek::(:)


Hi Lori,
That’s exactly how it feels … I was hoping this time around all would be good and we would get a 3 month break. I have to admit I am pretty worn out.

According to Dr Feldman about why dogs are not responding to Lysodren:


Possible explanations for resistance are the dog is not receiving or absorbing the drug (it should be administered after meals); the dog has an adrenocortical tumor; the diagnosis is incorrect; and the dog may have a resistant form of PDH.


Ok, now I am confused … I have read the part where Dr. Felman talks about dogs not responding several times and I would understand it if he said ‘the diagnosis is incorrect the dog has an adrenocortical tumor instead of PDH’ instead of listing ‘misdiagnosis’ as a separate reason altogether.
‘Resistant form of PDH’ – this I don’t understand either. I would like to know what the link is between the Lyso not being able to erode the adrenals and PDH.



Now I'm probably grabbing at straws here, so bear with me. If Phillip would have EPI (Exocrine Pancreatic Insufficiency), which one of the symptoms is a dog eating his poop bc he is very hungry, his Lysodren would not be absorbed bc his food remains undigested and unabsorbed. Now not all dogs with EPI carry the same symptoms, some have more severe and some less severe, so maybe in Phillip's case, if he would have EPI he's just not showing all of the typical signs?? I guess what I'm thinking here is that usually his Lysodren does actually get absorbed but there are days that it doesn't and maybe the EPI could be an explanation for that??


Well, its possible – it sure would explain the poor response to the Lyso. I liked the article – informative and to the point – thanks for the link.

I wish I would be able to consult with a specialist about all this – I feel I am way over my head making sense of all these issues. If he where to respond to the Lyso like the majority of the dogs do, I would feel quite confident that I would be able to make the right decisions but this is getting way to big.
I know here in Canada vets are not allowed to consult without seeing a dog but perhaps there is someone in the US who does phone/email consultations like Dr. Jean Dodds does for Thyroid issues?
What do you think?

Nathalie

Squirt's Mom
12-31-2009, 10:47 PM
I totally understand that a dog that is not being treated for cushings can have elevated cortisol levels due to conditions other then cushings.

Ya know...I was laying there in bed and it came to me that I believe we have already had this very conversation once before! And you are correct in that a treated pup would not have any excess cortisol to respond to the stress of a tumor like Squirt had. geez...old age is so much fun! :rolleyes::o

Buffaloe
01-01-2010, 10:47 AM
Hi Nathalie,

I don't think I have ever posted on your thread but was just reading through it this morning. My dog, Shiloh, had an adrenal tumor and had her adrenalectomy in 2006. She's 15 now and doing well for her age. I worked with some awfully good specialists and I learned alot from them. I'm going to mention some things and perhaps something will be helpful for you and Phillip.

Adrenal tumors are often resistant to Lysodren treatment. Higher and higher doses are often needed to try to control the cortisol. There are cases where dogs with adrenal tumors have required way, way higher doses of Lysodren than Phillip is getting. Obviously, there are downsides to a dog ingesting very large amounts of Lysodren.

An ultrasound is, by far, the best way to diagnose an adrenal tumor. Travelling ultrasonographers often use top quality, high res. machines. Another option would be to have the combination ACTH/LDDS/full adrenal panel performed by the U. of Tennessee. With Dr. Oliver's input, it is an excellent diagnostic test but an ultrasound is superior to any blood test, IMO.

You do have another very viable option to treat Phillip...Trilostane. Many, many Internists in the U.S. (especially the younger ones) prefer Trilostane to Lysodren for the treatment of adrenal tumors. I'll try to explain something: Think of the adrenal gland as the trunk of a tree with branches extending out. The branches are the pathway for cortisol and the various intermediate (sex) hormones. Trilostane blocks the branch that produces cortisol very effectively but not some of the branches for intermediate hormones. Lysodren obviously decreases the size of the whole trunk and thus generally lessens the elevated intermediate hormones more effectively than Trilostane. Terri (Corky's mom) is treating Corky's adrenal tumor effectively with Trilostane with the help of a sharp, young Internist.

I have no idea whether or not Phillip has an adrenal tumor but it sounds like a definite possibility. You have gone way beyond the call of duty with Phillip and he has certainly benefitted greatly from your wonderful care. You gotta keep the faith. All the best to you and Phillip.

Ken

Nathalie
01-01-2010, 07:47 PM
Thank you All for your thoughts, comments and suggestions it is so much appreciated!
For now I have increased his maintenance dose to 3000 mg which should buy me a few weeks until his next stim test unless something else comes up. For some reason I thought Trilostan is not effective if an adrenal tumor is present and when I mentioned this to the vet on Tuesday she did not correct me either – thanks for bringing this up.
I believe that with Trilostan there is really no way of knowing which dose will be effective after slowly increasing. Would it be possibly to make an educated guess based on experience? I am looking for an estimated highest dose a dog weighing 63 lbs could possibly need in order to find out if financially Trilostan is even an option.
Also, if I where to switch to Trilostan, would I need to do a full adrenal panel after the 30 wash-out period?

Thanks,
Nathalie

littleone1
01-02-2010, 12:38 AM
Hi Nathalie,

Corky was 20.6 pounds when he started taking Trilostane. Corky has a right adrenal tumor, and even though an adrenalectomy would be the best way to go, surgery is not a good option for Corky. His IMS started him on a low dose of 20 mg once a day. After his 30 day stim test, she is keeping Corky on that dosage. This would be the lower dose of 1-3 mg per pound. According to Dechra's dosing chart, it does say that Trilo can be used to treat an adrenal tumor. The Trilo doesn't get rid of the tumor, but it does clear up the clinical signs and helps control the amount of cortisol that is being released.

I have found that Trilo is much less expensive than Lysodren. Originally when Corky was diagnosed with Cushings, his vet was putting Corky on Lyso. I paid $128.00 for 30 tablets, which I never used. Now I pay $23.75 for 30 capsules of Trilo.

I really don't know if you would have to have a complete adrenal panel done. Corky had one done after being on Trilo for 10 days, so there was no washout time. I would ask your vet about this.

I hope that you will be able to get your questions answered, and that Phillip will be okay.

Buffaloe
01-02-2010, 01:08 AM
Nathalie,

I'm hopeful and I believe there is an excellent chance that the 3000 mg. maintenance dose will effectively control Phillip's cortisol level. His Dec. post number of 3.87 is really good. I realize it went up a bit from his previous ACTH test but that is an excellent number. And it sounds like he is feeling pretty well so there are alot of positives.

I was just trying to say that you do have another option (Trilostane) if it gets to the point that Lysodren is not controlling his cortisol well enough. I sure don't think you should consider switching at this point. In an ideal world they like to do a full 30 day washout before switching to Trilostane. However, I believe if symptoms return significantly, they make the switch sooner.

Some dogs with adrenal tumors are treated with a maintenance dose of Lysodren of 150 mg/kg. of body weight. That is much higher than what Phillip will be getting. Toxicity has to be a concern with such high doses. I sure didn't mean to give you the impression that I thought you should switch to Trilostane. I was just saying, you do have another option at some point down the road if you should need it.

Treating adrenal tumors medically is a little difficult and I'm sure no expert. For what it's worth, I think you are proceeding exactly right with Phillip. I believe he will handle the 3000 mg/week of Lysodren just fine and I think this dose has a great chance of controlling his cortisol level effectively.

We're pulling for you and Phillip all the way.

Ken

Squirt's Mom
01-02-2010, 10:42 AM
Hi Nathalie,

I had a doc (human) tell me something years ago about having to take mega doses of a certain med I was concerned about that may help ease your mind a bit. He told me that if I were taking that dose when it wasn't needed, my body would react badly to it; however, it was needed, my body recognized that need, and so the dose would not cause the same reactions I might experience it I took it "just for fun." He must have been right because I didn't experience any of the reactions the drug was known for and that I feared - my body put it all to use as intended.

Hopefully, Phillip's body will look at the Lyso in the same way - as something necessary not extraneous.

Hugs,
Leslie and the girls - always

lulusmom
01-02-2010, 11:33 AM
Hi Nathalie,

Unless the last and prior acth stimulation tests were performed under identical conditions, the less than one point increase on the last stim may not be an indication that the adrenals are regenerating. Were both tests done approximately 48 hours after the last Lyso dose and was the dose prior to the stim given with the exact food or treat?

I have two dogs on Lysodren and their respective stim tests are rarely identical. Sometimes they are higher and sometimes they are lower, depending on the timing. I honestly believe that whether I dosed them with cream cheese or peanut butter can make a difference. As long as their post stim is between 2 and 4, we are happy.

Glynda

Nathalie
01-02-2010, 02:49 PM
Unless the last and prior acth stimulation tests were performed under identical conditions, the less than one point increase on the last stim may not be an indication that the adrenals are regenerating. Were both tests done approximately 48 hours after the last Lyso dose and was the dose prior to the stim given with the exact food or treat?

I have two dogs on Lysodren and their respective stim tests are rarely identical. Sometimes they are higher and sometimes they are lower, depending on the timing. I honestly believe that whether I dosed them with cream cheese or peanut butter can make a difference. As long as their post stim is between 2 and 4, we are happy.


Hi Glynda,
Interesting, I never even considered there could be this much of a fluctuation depending when the stim test was done, food etc. Thanks for bringing this up.
I give him his Lyso divided in 4 doses of 750 mg on Thursday, Saturday, Sunday and Tuesday and I always take him in on Tuesday mornings for his stim tests which is about 38 h after his last dose – no variations in food. But again – perhaps some days he absorbs the drug better then others …
The reason I panic when his numbers seem to go up is because he has never been stable before and I do not want to have to do a mini load again.

Ok – this is working – I am not freaking out anymore. Perhaps 3000mg will be ok – I don’t know what I would do without you guy’s!!!:D:o:D

I am also reconsidering having the U/S done. Which means I can’t do the full blood work and Acid/Bile test in 4 weeks. Do you think this could wait another 2 months or unless Phillips shows signs of not being able to tolerate the dose? How often to you guy’s do full blood work? We just did all this October 28.

BTW – Phillip seems to be feeling just fine – quite perky actually – go figure. :rolleyes:
Nathalie

Nathalie
01-27-2010, 03:33 PM
It does not look like this is meant to happen for us .. did another stim test yesterday and it is up from last time by over 1 point
Here are his last 4 test results including the maintenance dose Phillip was on prior to the test:

October 28:
Pre: < 0.36
Post: 3.2 (after mini load)

December 2: (2750mg)
Pre: 1.3
Post:2.97

December 29: (2750mg)
Pre: 1.63
Post:3.87

January 26: (3000mg)
Pre: 2.46
Post: 4.93

Phillip’s vet suggested that instead of only increasing by 250mg per week to up his dose by 500mg to a total of 3500mg. I tend to agree that a 250mg increase probably won’t maintain the level.
She called the lab to run a full liver panel to make sure he can actually handle it. She also looked into the costs of switching him to Trilostan assuming he will require a very high dose and the cost would be $466 per month. Even if it would be somewhat less, the monthly costs would not be something I could afford on top of the cost for monitoring and I don’t see a point in even attempting to switch him over in hopes that he only will require a very low does because if he doesn’t I would have to stop treatment because of funds.

I know that I said I would not do an US but I changed my mind and if we can get an appointment I will take him in on Friday. Not that it would change anything we can do for him but perhaps the findings will help making a decision when enough is enough. The lump on his right elbow has been growing too and before I got yesterdays test results we decided we should remove it as long it is still small enough so it can be done under local anesthetic. The removal is the easy part it is the healing that could make things worse so depending on the US results there might be no point in putting him though this and possibly ending up with an infection or an area we can’t get to heal properly.

The sad part is that he is quite perky, alert so does not really appear like he is sick at all - he is just a little slower at 12.5 but still enjous long walks and chasing squirrels. But I can already see his appetite increasing and his left eye tearing which is just part of his symptoms when the cortisol is rising.

I would appreciate any comments, suggestions and thoughts any of you have. Perhaps there is an angel to this I am not seeing that we could explore.

Thanks,
Nathalie

Franklin'sMum
01-28-2010, 05:23 AM
Hi Nathalie,

Nothing constructive to say :o, but you and Phillip are in my thoughts and prayers.

Jane and Franklin xx
________
WhiteStar (http://www.girlcamfriend.com/cam/WhiteStar/)

Squirt's Mom
01-28-2010, 12:36 PM
Hi Nathalie,

His numbers are still creeping up, aren't they? I seem to remember reading at some point that some pups are resistant to Lyso, just as some of us humans don't respond as well to all meds the same. You might want to ask your vets about this and see what they know, 'cause that's all my little memory seems to have on the topic! :o

I do think getting the U/S is a wise move. You may find the reason for his apparent resistance, his inability to get control and keep it even with high doses. Knowledge is power. Phillip has been demonstrating for some time that something isn't quite right so the U/S is a very good move. Finding something there doesn't mean surgery will be required, but it would mean you know better what you are dealing with and can perhaps find other options to surgery.

Sending healing thoughts and prayers for you both,
Hugs,
Leslie and the girls - always

Nathalie
01-28-2010, 01:27 PM
Thanks Jane and Leslie.
Yes, when Phillip's vet talked about his poor response to Lyso with a specialist in the states, she mentioned that there are just some dogs that do not respond well to Lyso and to switch him over to Trilo.

It will be interresting to see what the US shows. I hope it does give us same helpful information.

Just got of the phone with the vet and his Liver panel results are pretty damm good - the only elevation we have is the ALK Phos at 2900 which was up last time to over 4000 but he also had pancreatitis at the time. So overall he is dealing with the high Lyso dose not too bad so far - who would have thought???

The US is confirmed for tomorrow morning. Will keep you posted.
Nathalie

Harley PoMMom
01-28-2010, 06:26 PM
Hi Nathalie,

I wish I had some words of wisdom for you...I do think the u/s would be useful in knowing, hopefully, whether Phillip does indeed have an adrenal tumor or not.

Will be keeping you and Phillip in my thoughts and prayers, my dear friend.

With much love and big hugs,
Lori

Roxee's Dad
01-28-2010, 07:34 PM
Hi Nathalie,
No advice to offer but I do offer up my hopes, good thoughts and prayers for good ole Phillip. :) I know you've had a tough time of it and it seems Phillip is very special as he also doesn't follow the k9cushings rule book. :(

Buffaloe
01-28-2010, 08:35 PM
Hi Nathalie,

Phillip's cortisol level still is not rising a whole lot. :):). And his significantly decreased level of alk. phos. is excellent news. I realize he had pancreatitis when his level was at 4000 but I still think it's really good news. I hope your ultrasound is crystal clear and all of Phillip's organs look good and healthy.

Ken

Nathalie
01-29-2010, 05:04 PM
Today was US day…… this blew me away …

NO tumors, nothing!!! :D:D:D
The Liver is slightly enlarged but look good. Gallbladder looks great. Spleen had some ‘spots’ but normal for his age. Gallbladder normal.
Adrenal glands were bilaterally normal to modestly enlarged, measuring 0,74 and 0.8 cm in diameter (n< 0.75 cm) pm the right side respectively. No evidence of adrenal neoplasia was seen. These findings are confirming your diagnosis and are implying acceptable but not ideal control of hyperadrenocoriticism.

The IM Specialist recommended a slight increase in dose of Lyso. He thinks that the increase from 3000 to 3500mg should probably adequate because the one adrenal is only slightly enlarged.

I mean I am happy about the result but this is not what I expected. Here I was worried about cancer and tumors and the guy is a bloody poor responder to the Lyso but otherwise pretty healthy – go figure. ;):o;)

To top it all of, when I looked at his liver panel even his ALT came down another notch from 51 to 38 (5-95). :)

Thanks for all the good wishes – now I am glad I did the US because now I don’t have to worry so much anymore. I truly felt I am poisoning him and expected his liver to be in terrible shape as well as a massive tumor.

Nathalie
BTW: Phillip was fantastic during the US – he did not needed to be shaved which was a bonus and did not move or struggle and the person doing the US thanked me for bringing him in and that he was lovely to work with.